PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
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1 ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H G0396 ICD10 Mental, Behavioral and Neurodevelopmental disorders G0397 ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders
2 CHEMICAL DEPENDENCY Chemical Dependency/Substance Abuse* (MA Only) ICD10 Mental, Behavioral and Neurodevelopmental disorders CLINICAL TRIALS DME Clinical Trials Bone growth stimulators Not specific to codes, must be indicated on submitted request. May have 8 digit trial ID, or primary or secondary Dx of Z00.6 E0747 E0748 E0760 Chest compression devices C-Pap* Bi-Pap* Enteral/Parenteral Feedings* For individuals 21 and over ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders E0483 E0561 E0562 E0601 E0470 E0471 E0472 B4100 B4102 B4103 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159
3 DME Enteral/Parenteral Feedings* B4160 For individuals 21 and over B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 Hospital beds & accessories* B4199 B4216 B4220 B4222 B4224 B5000 B5100 B9000 B9002 B9004 B9006 B9998 B9999 E0193 E0194 E0250 E0251 E0255 E0256 E0260 E0261 E0266 E0277 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0300 E0301 E0302
4 DME Hospital beds & accessories* E0303 E0304 E0316 E0328 E0329 E0371 E0372 E0373 Oxygen* E1390 E1391 E1392 E0441 E0442 E0443 E0444 E0445 Ventilators* A4611 A4612 A4613 E0465 E0466 Wheelchair/Scooters* E1002 E1007 E1008 E1010 E1029 E1030 E1031 E1060 E1070 E1161 E1229 E1230 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E2300 E2325 E2373 E8001 K0001 K0002 K0003 K0004
5 DME Wheelchair/Scooters* K0005 K0006 K0007 K0009 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861
6 DME Wheelchair/Scooters* K0862 K0863 K0890 K0891 K0898 Wound Vac A6550 E2402 All DME > $500 allowed amount per line item or > $1000 total allowed amount. For specific codes refer to the plan's fee schedule. Prosthetics and Orthotics L0170 L0456 L0464 L0480 L0482 L0486 L0631 L0637 L0640 L1005 L1200 L1300 L1499 L1730 L1834 L1844 L1845 L1846 L1945 L1950 L1970 L2020 L2034 L2036 L2037 L2038 L2108 L2136 L2350 L3230 L3720 L3730 L3740 L3764 L3900 L3905 L5020 L5050 L5100 L5220
7 DME Prosthetics and Orthotics L5301 L5321 L5400 L5510 L5530 L5540 L5590 L5646 L5651 L5661 L5703 L5790 L5812 L5814 L5828 L5848 L5930 L5950 L5964 L5968 L5976 L5980 L5981 L5984 L5987 L5988 L6000 L6050 L6100 L6300 L6687 L6689 L6694 L6704 L6707 L6884 L7405 L8619 L8691 L8692 DME MISC. Speech Generating Device E2510 GENETIC TESTING/COUNSELING Genetic counseling not related to pregnancy* (pregnancy indicated by Dx)
8 GENETIC TESTING/COUNSELING Genetic counseling not related to pregnancy* (pregnancy indicated by Dx)
9 GENETIC TESTING/COUNSELING Genetic counseling not related to pregnancy* (pregnancy indicated by Dx)
10 GENETIC TESTING/COUNSELING Genetic counseling not related to pregnancy* (pregnancy indicated by Dx) G9143
11 INJECTABLE DRUGS Abatacept (Orencia) J0129 Adalimumab (Humira) J0135 Ado-trastuzumab Emtansine (Kadcyla) Alemtuzumab (Lemtrada) Aprepitant (Cinvanti) Atezolizumab Avelumab Ziv-Afibercept (Zaltrap) Belimumab (Benlysta) Botulinum Toxin (Botox/Myobloc/Dysport/Xeomin) J9354 J0202 C9463 J9022 J9023 J9400 J0490 J0585 INJECTABLE DRUGS Brentuximab (Adcetris) Buprenorphine implant (Probuphine) Buprenorphine xr subcutaneous injection Canakinumab (Ilaris) Cetuxumab (Erbitux) Denosumab (Prolia/ Xgeva) Durvalumab Ecallantide (Kalbitor) Edaravone Epoprostenol (Flolan, Veletri) Erythropoiesis-Stimulating Agents (Darbepoetin/Epoetin) Filgrastim - biosimilar Zarxio GnRH Agonists (Lupron) Golimumab (Simponi Aria) Granisetron extended-release Granulocyte-Colony Stimulating Factor (G-Csf) (e.g., Pegfilgrastim, Filgastrim, Sargramostim) Growth Hormone (Somatropin) Hyaluronic acid (Durolane) Hyaluronic Acid Derivatives (Synvisc, Hyalgan) J0586 J0587 J0588 J9042 J0570 Q9991 Q9992 J0638 J9055 J0897 C9492 J1290 C9493 J1325 J0881 J0882 J0885 J0887 J0888 Q4081 Q5101 J1950 J1602 J1627 J1447 J1442 J2505 J2820 J2941 C9465 J7320 J7321 J7322 J7323
12 INJECTABLE DRUGS Hyaluronic Acid Derivatives (Synvisc, Hyalgan) J7324 J7325 J7326 J7327 J7328 Hydroxyprogesterone Caproate (Makena) J1726 Medicaid: Pharmacy Benefit - Please direct prescription to Accredo Specialty Pharmacy, phone Medicare: Prior Authorization is required. Hydroxyprogesterone Caproate J1729 Medicaid: Pharmacy Benefit - Please direct prescription to Accredo Specialty Pharmacy, phone Medicare: Prior Authorization is required. Ibandronate (Boniva) Infliximab (Remicade) Infliximab biosimilar, Inflectra Infliximab-abda, biosimilar, (Renflexis) Injection, somatrem, 1 mg Intravenous Immunoglobulin Ipilimumab (Yervoy) Lymphocyte immune globulin, Atgam Mempolizumab (Nacala) Natalizumab (Tysabri) Nivolumab (Opdivo) Ocrelizumab, 1 mg Omalizumab (Xolair) Paclitaxel protein bound (Abraxane) Paclitaxel (Taxol) J1740 J1745 Q5103 Q5104 J2940 J0588 J1459 J1557 J1561 J1566 J1568 J1569 J1572 J7504 J1556 J1559 J1555 J1562 J1599 J1575 J9228 J7504 J2182 J2323 J9299 J2350 J2357 J9264 J9267 Palivizumab (Synagis) Panitumumab (Vectibix) Pegloticase (Krystexxa) Pembrolizumab (Keytruda) Pemetrexed (Alimta) Pertuzumab (Perjeta) Ramucirumab (Cyramza) Ranibizumab (Lucentis) J9303 J2507 J9271 J9305 J9306 J9308 J2778
13 INJECTABLE DRUGS Reslizumab (Cinqair) J2786 OUTPATIENT SPECIALTY SERVICES Rituximab (Rituxan) Inj rituximab hyaluronidase (Rituxan Hycela) Trastuzumab (Herceptin) Tocilizumab (Actemra) Treprostinil (Remodulin) Treprostinil (Remodulin) Ustekinumab (Stelara) Ustekinumab (Stelara) Vedolizumab (Entyvio) Zoledronic Acid (Zometa, Reclast) Unclassified Biologics Chiropractic* (greater than 12 visits MA and qualifying AH under age 20) J9310 C9467 J9355 J3262 J3285 J7686 J3357 J3358 J3380 J3489 J Hyperbaric Oxygen Treatment G Orthoptic/Pleoptic Training: therapy services associated with orthoptic and pleoptic will require a PA. See PT and OT therapy notes below Physical Therapy* (after 12 visits MA; after 12 visits age 20 and under WAH; after 6 hours (24 units) WAH age 21 and over) **EXCEPTION TO THE ABOVE: Optometrist billing for therapy services will require a PA regardless of diagnosis before services begin
14 OUTPATIENT SPECIALTY SERVICES Physical Therapy* (after 12 visits MA; after 12 visits age 20 and under WAH; after 6 hours (24 units) WAH age 21 and over) **EXCEPTION TO THE ABOVE: Optometrist billing for therapy services will require a PA regardless of diagnosis before services begin. Occupational Therapy* (after 12 visits MA; after 12 visits age 20 and under WAH; after 6 hours (24 units) WAH age 21 and over) **EXCEPTION TO THE ABOVE: Optometrist billing for therapy services will require a PA regardless of diagnosis before services begin. Speech Therapy* (after 12 visits MA; after 6 visits WAH 21 and over) OTHER PSYCHIATRIC SERVICES IMAGING/RADIOLOGY Electroconvulsive therapy/therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (WAH only) Medical Radiation Physics, dosimetry, treatment devices and special services (WAH only) MRI G
15 IMAGING/RADIOLOGY MRI C8903 C8904 C8905 C8906
16 IMAGING/RADIOLOGY MRI C8907 C8908 MRA C8900 C8901 C8902 C8909 C8910 C8911 C8912 C8920 C8931 C8932 C8933 C8934 C8935 C8936 Proton Beam Treatment (WAH only) SURGICAL PROCEDURES Bariatric surgery
17 SURGICAL PROCEDURES Bariatric surgery Cochlear implant Endovenous laser/radiofrequency ablation Hysterectomy
18 SURGICAL PROCEDURES Knee Arthroscopy Mammoplasty (Augmentation/Reduction) **excludes ICD 10 cancer dx S2066 S2067 S2068 Nervous system (facet neurotomy) Reconstructive plastic surgery & supplies
19 SURGICAL PROCEDURES Reconstructive plastic surgery & supplies Rhinoplasty and septoplasty Sclerotherapy, leg veins Shoulder Arthroscopy Spinal Injections
20 SURGICAL PROCEDURES Spinal Injections Spinal surgeries
21 SURGICAL PROCEDURES Spinal surgeries
22 SURGICAL PROCEDURES Spinal surgeries
23 SURGICAL PROCEDURES Spinal surgeries TRANSPLANTS Transplant
24 TRANSPLANTS Transplant Transplant Eval and WorkUp T Transplant evaluation and workup includes standard office visits for determining patients viability for services. Tests and treatments outside of the approved evaluation and treatment will be subject to review under the remainder of the PA List
PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
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INJECTION, INOTUZUMAB OZOGAMICIN, 0.1 MG [BESPONSA ] [C CODES FOR FACILITY USE ONLY]
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Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD
Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
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J0586 ABOBOTULINUMTOXINA Dysport X X X the medication is being used to treat J0178 AFLIBERCEPT Eylea X X X X X of Neovascular (Wet) -Related Macular Degeneration of Macular Edema following either central
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not require PA. review. MHT
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