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1 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Punch graft for hair transplant; 1 to 15 punch grafts" PPO/ Punch graft for hair transplant; more than 15 punch grafts PPO/ Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids) PPO/ Dermabrasion; segmental, face PPO/ Dermabrasion; regional, other than face PPO/ Abrasion; single lesion (eg, keratosis, scar) PPO/ Abrasion; each additional 4 lesions or less PPO/ Chemical peel, facial; epidermal PPO/ Chemical peel, facial; dermal PPO/ Chemical peel, nonfacial; epidermal PPO/ Chemical peel, nonfacial; dermal PPO/ Cervicoplasty PPO/ Blepharoplasty, lower eyelid; PPO/ Blepharoplasty, lower eyelid; with extensive herniated fat pad PPO/ Blepharoplasty, upper eyelid; PPO/ Blepharoplasty, upper eyelid; with excessive skin weighting down lid PPO/ Rhytidectomy; forehead NON COVERED BY ORIGINAL MEDICARE Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) NON COVERED BY ORIGINAL MEDICARE January 2019 Page 1

2 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Rhytidectomy; glabellar frown lines NON COVERED BY ORIGINAL MEDICARE Rhytidectomy; cheek, chin, and neck Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy NON COVERED BY ORIGINAL MEDICARE NON COVERED BY ORIGINAL MEDICARE PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or PPO/ hand Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental PPO/ fat pad Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area PPO/ Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen PPO/ (eg, abdominoplasty) (includes umbilical transposition and fascial plication) Suction assisted lipectomy; head and neck NON COVERED BY ORIGINAL MEDICARE Suction assisted lipectomy; trunk NON COVERED BY ORIGINAL MEDICARE January 2019 Page 2

3 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Suction assisted lipectomy; upper extremity NON COVERED BY ORIGINAL MEDICARE Suction assisted lipectomy; lower extremity NON COVERED BY ORIGINAL MEDICARE Destruction of cutaneous vascular proliferative lesions (eg, laser technique); Less than 10 sq cm PPO/ Destruction of cutaneous vascular proliferative lesions (eg, laser technique): 10.0 to 50.0 sq cm PPO/ Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq. cm. PPO/ Cryotherapy (CO2 slush, liquid N2) for acne PPO/ Electrolysis epilation, each 30 minutes PPO/ Reduction mammaplasty PPO/ Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant Removal of intact mammary implant PPO/ Removal of mammary implant material PPO/ Breast reconstruction, immediate or delayed, with tissue expander PPO/ Open periprosthetic capsulotomy, breast PPO/ Periprosthetic capsulectomy, breast PPO/ Revision of reconstructed breast PPO/ January 2019 Page 3

4 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) Additional Comments: Requires prior approval if associated with a TMJ diagnosis. Please see medical coverage policy for temporomandibular joint surgery Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Additional Comments: Requires prior approval if associated with a TMJ diagnosis. Please see medical coverage policy for temporomandibular joint surgery Electrical stimulation to aid bone healing; noninvasive (nonoperative) Electrical stimulation to aid bone healing; invasive (operative) Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Arthrotomy, temporomandibular joint Condylectomy, temporomandibular joint Meniscectomy, partial or complete, temporomandibular joint Coronoidectomy Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an NON COVERED BY anesthesia service ORIGINAL MEDICARE Impression and custom preparation; surgical obturator prosthesis Impression and custom preparation; orbital prosthesis January 2019 Page 4

5 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Impression and custom preparation; interim obturator prosthesis Impression and custom preparation; definitive obturator prosthesis Impression and custom preparation; mandibular resection prosthesis Impression and custom preparation; palatal augmentation prosthesis Impression and custom preparation; palatal lift prosthesis Impression and custom preparation; speech aid prosthesis Impression and custom preparation; oral surgical splint Impression and custom preparation; auricular prosthesis Impression and custom preparation; nasal prosthesis Impression and custom preparation; facial prosthesis Application of interdental fixation device for conditions other than fracture, includes removal Injection procedure for temporomandibular joint arthrography Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material Reduction forehead; contouring and setback of anterior frontal sinus wall Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) Arthroplasty, temporomandibular joint, with allograft Arthroplasty, temporomandibular joint, with prosthetic joint replacement Reconstruction of mandible, extraoral, with transosteal bone plate January 2019 Page 5

6 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Reconstruction of mandibular condyle with bone and cartilage autografts Reconstruction of mandible or maxilla, endosteal implant Reconstruction of mandible or maxilla, endosteal implant Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage Reconstruction of orbit with osteotomies (extracranial) and with bone graft Periorbital osteotomies for orbital hypertelorism, with bone grafts; Periorbital osteotomies for orbital hypertelorism, with bone grafts; Periorbital osteotomies for orbital hypertelorism, with bone grafts; Orbital repositioning, periorbital osteotomies, unilateral, Secondary revision of orbitocraniofacial reconstruction Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilaterial Non Covered by Original Medicare Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilaterial Non Covered by Original Medicare Reconstruction, toe(s); syndactyly, with or without skin graft(s), each Reconstruction, cleft foot Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy Arthroscopy, temporomandibular joint, surgical Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip PPO/ January 2019 Page 6

7 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Rhinoplasty, primary; including major septal repair Removal of lung, other than total pneumonectomy; excision-plication emphysematous lung(s) Donor pneumonectomy(s) (including cold preservation), from cadaver donor Lung transplant, single; without cardiopulmonary bypass Lung transplant, single; with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass Backbench standard preparation of cadaver donor lung allograft prior to transplantation Backbench standard preparation of cadaver donor lung allograft prior to transplantation Donor cardiectomy-pneumonectomy (including cold preservation) Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation Heart-lung transplant with recipient cardiectomy-pneumonectomy Donor cardiectomy (including cold preservation) Backbench standard preparation of cadaver donor heart allograft prior to transplantation Heart transplant, with or without recipient cardiectomy January 2019 Page 7

8 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg Single or multiple injections of sclerosing solutions, spider veins (telangiectasia), limb or trunk Injection of sclerosing solution; single vein Injection of sclerosing solution; multiple veins, same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity Endovenous ablation therapy of incompetent vein, extremity Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites January 2019 Page 8

9 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below Ligation and division and complete stripping of long or short saphenous Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, Stab phlebectomy 1 leg of varicose veins, 1 extremity; stab incisions Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions Ligation and division of short saphenous vein at saphenopopliteal junction Ligation, division, and/or excision of varicose vein cluster(s), 1 leg Management of recipient hematopoietic progenitor cell donor search and cell acquisition Blood-derived hematopoietic progenitor cell harvesting for transplantation; allogenic January 2019 Page 9

10 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Blood-derived hematopoietic progenitor cell harvesting for transplantation; autologous Transplant preparation of hematopoietic progenitor cells; cryopreservative Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing Transplant preparation of hematopoietic progenitor cells; specific cell Transplant preparation of hematopoietic progenitor cells; tumor cell depletion Transplant preparation of hematopoietic progenitor cells; red blood cell Transplant preparation of hematopoietic progenitor cells; platelet depletion Transplant preparation of hematopoietic progenitor cells; plasma Transplant preparation of hematopoietic progenitor cells; cell concentration Bone marrow harvesting for transplantation Bone marrow or blood-derived peripheral stem cell transplantation; Allogenic Bone marrow or blood-derived peripheral stem cell transplantation; autologous Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions Tongue base suspension, permanent suture technique Removal of embedded foreign body from dentoalveolar structures; soft tissue Removal of embedded foreign body from dentoalveolar structures; bone January 2019 Page 10

11 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Gingivectomy, excision gingiva, each quadrant Operculectomy, excision pericoronal tissues Excision of fibrous tuberosities, dentoalveolar structures Excision of osseous tuberosities, dentoalveolar structures Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair Excision of hyperplastic alveolar mucosa, each quadrant (specify) Alveolectomy, including curettage of osteitis or sequestrectomy Destruction of lesion (except excision), dentoalveolar structures Periodontal mucosal grafting Gingivoplasty, each quadrant (specify) Alveoloplasty, each quadrant (specify) Resection of palate or extensive resection of lesion Uvulectomy, excision of uvula Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty Maxillary impression for palatal prosthesis Insertion of pin-retained palatal prosthesis January 2019 Page 11

12 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Pharyngoplasty (plastic or reconstructive operation on pharynx Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Rouxen-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; verticalbanded gastroplasty NON COVERED BY ORIGINAL MEDICARE Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption Gastric restrictive (biliopancreatic procedure, diversion with gastric with duodenal bypass for switch) morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption January 2019 Page 12

13 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Implantation or replacement of gastric neurostimulator electrodes, Revision or removal of gastric neurostimulator electrodes, antrum, open Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only NON COVERED BY ORIGINAL MEDICARE NON COVERED BY ORIGINAL MEDICARE NON COVERED BY ORIGINAL MEDICARE Donor enterectomy (including cold preservation), open; from cadaver Donor enterectomy (including cold preservation), open; partial, from living donor Intestinal allotransplantation; from cadaver donor Intestinal allotransplantation; from living donor Backbench standard preparation of cadaver or living donor intestine Backbench reconstruction of cadaver or living donor intestine allograft Backbench reconstruction of cadaver or living donor intestine allograft Donor hepatectomy (including cold preservation), from cadaver donor Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) January 2019 Page 13

14 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments V, VI, VII and VIII) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation Transplantation of pancreatic allograft January 2019 Page 14

15 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Removal of transplanted pancreatic allograft Donor nephrectomy (including cold preservation); from cadaver donor Donor nephrectomy (including cold preservation); open, from living donor Backbench standard preparation of cadaver donor renal allograft prior to transplantation Backbench standard preparation of living donor renal allograft Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation Recipient nephrectomy (separate procedure) Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation/reimplantation of kidney Laparoscopy, surgical; donor nephrectomy (including cold preservation), Insertion of a temporary prostatic urethral stent, including urethral measurement Plastic operation on penis to correct angulation Insertion of penile prosthesis; non-inflatable (semi-rigid) Insertion of penile prosthesis; inflatable (self-contained) January 2019 Page 15

16 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Repair of component(s) of a multi-component, inflatable penile prosthesis Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Insertion of testicular prosthesis (separate procedure) Scrotoplasty; simple Scrotoplasty; complicated Construction of artificial vagina; without graft Construction of artificial vagina; with graft Revision (including removal) of prosthetic vaginal graft; vaginal approach Revision (including removal) of prosthetic vaginal graft; open abdominal approach Tubotubal anastomosis Salpingostomy (salpingoneostomy) January 2019 Page 16

17 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays Percutaneous implantation of neurostimulator electrodes; cranial nerve Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator Incision for implantation of neurostimulator electrodes; Cranial nerve Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling Radial keratotomy Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) January 2019 Page 17

18 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-muller's muscle-levator resection (eg, Fasanella-Servat type) Reduction of overcorrection of ptosis Correction of lid retraction Canthoplasty (reconstruction of canthus) Radiologic examination, teeth; single view Radiologic examination, teeth; partial examination, less than full mouth Radiologic examination, teeth; complete, full mouth Cephalogram, orthodontic Stem cells (ie, CD34), total count Psychiatric diagnostic interview examination Psychiatric diagnostic evaluation with medical services Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual January 2019 Page 18

19 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Behavioral and qualitative analysis of voice and resonance Treatment of swallowing dysfunction and/or oral function for feeding Additional Comments: Requires prior approval if performed by a speech therapist in outpatient setting Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour Therapeutic service(s) for the use of non-speech-generating device, Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour January 2019 Page 19

20 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) Therapeutic services for the use of speech-generating device, including programming and modification Evaluation of oral and pharyngeal swallowing function Motion fluoroscopic evaluation of swallowing function by cine or video recording Evaluation of auditory rehabilitation status; first hour Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure) Auditory rehabilitation; prelingual hearing loss Auditory rehabilitation; postlingual hearing loss Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) Additional Comments: Requires prior approval if services performed as part of a cardiac rehabilitation program and the service is beyond the initial 36 visits. Please refer to the medical coverage policy for cardiac rehabilitation Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) Additional Comments: Requires prior approval if services performed as part of a cardiac rehabilitation program and the service is beyond the initial 36 visits. Please refer to the medical coverage policy for cardiac rehabilitation January 2019 Page 20

21 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour Developmental screening, with interpretation and report, per standardized instrument form Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure) Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results Neurobehavioral and preparing status the exam report (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure) January 2019 Page 21

22 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-toface time administering tests to the patient and time interpreting these test results and preparing the report Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; Neuropsychological each additional testing hour evaluation (List separately services by in physician addition to or code other for qualified primary health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and Neuropsychological interactive feedback testing to the evaluation patient, services family member(s) by physician or caregiver(s), or other qualified when health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and Psychological interactive or feedback neuropsychological to the patient, test family administration member(s) and or caregiver(s), scoring by physician when or other qualified health care professional, two or more tests, any method; first 30 minutes Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure) January 2019 Page 22

23 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure) Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure) Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure) January 2019 Page 23

24 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure) Home infusion/specialty drug administration, per visit (up to 2 hours); PPO/ Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure) PPO/ Pulmonary rehabilitation, including exercise (includes monitoring), one hour, G0424 S0215 S5497 S5498 S5501 Additional Comments: Requires prior approval if services performed as part of a pulmonary rehabilitation program and the service is beyond the initial 36 visits. Please refer to the medical coverage policy for pulmonary rehabilitation Nonemergency transportation; mileage, per mile Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), Home infusion per therapy, diem catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 24

25 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. S5502 Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S5517 Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting S5518 Home infusion therapy, all supplies necessary for catheter repair S5520 Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (PICC) line insertion S5521 Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC), nursing services only (no supplies or catheter included) S5523 Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included) Home infusion therapy, pain management infusion; administrative services, S9325 professional pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem S9326 S9327 Home infusion therapy, continuous (24 hours or more) pain management infusion; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, intermittent (less than 24 hours) pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 25

26 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. S9328 Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9329 S9330 S9331 S9336 S9338 S9346 S9347 Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, continuous (24 hours or more) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, intermittent (less than 24 hours) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment per diem Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin), administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment per diem Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs Home infusion and nursing therapy, visits alpha-1-proteinase coded separately), inhibitor per diem (e.g., Prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 26

27 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., S9348 Dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, tocolytic infusion therapy; administrative services, S9349 professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, continuous or intermittent antiemetic infusion therapy; S9351 administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and visits coded separately), per diem Home infusion therapy, continuous insulin infusion therapy; administrative services, S9353 professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9355 S9357 S9359 S9361 Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, enzyme replacement intravenous therapy; (e.g., Imiglucerase); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antitumor necrosis factor intravenous therapy; (e.g., Infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 27

28 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. Home infusion therapy, antispasmotic therapy; administrative services, professional S9363 pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9373 Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9374 Home infusion therapy, hydration therapy; 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment Home infusion (drugs therapy, and nursing hydration visits therapy; coded more separately), than 1 liter per diem but no more than 2 liters S9375 per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, hydration therapy; more than 2 liters but no more than 3 S9376 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, hydration therapy; more than 3 liters per day, administrative S9377 services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem S9379 S9490 Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 28

29 SPECIAL NOTES: Please refer to the Blue Medicare Medical Coverage Policies for If Original Medicare does not cover the specific service Blue Medicare does not cover not be considered for coverage by Blue Medicare. S9494 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately, per diem) S9497 S9500 S9501 S9502 S9503 S9504 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem January 2019 Page 29