AIM Specialty Health

Transcription

1 GA Standard Preapproval CODE List (06/01/18) Eligibility and benefits Eligibility and benefits can be verified by accessing the BCBSGa/BCBSHP web site bcbsga.com or by calling the number on the back of the member s identification card. Service preapproval is based on member s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain preapproval prior to rendering the designated services listed below will result in denial of reimbursement. This document includes 4 sections: AIM Specialty Health, AIM Musculoskeletal (MSK) Program, AIM Reviews, Anthem Medical Policy or Clinical Guideline Content Transfers and GA Standard Preapproval Codes classified by DRG, Medical Policy and Clinical Guideline. Deletions could be reviewed post-service. AIM Specialty Health AIM Specialty Health, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of GA for certain health plan members. Determine if preapproval is needed for a GA member by clicking the Medical Policy, Clinical UM Guidelines, and Preapproval Requirements link on our provider website, or by calling the preapproval phone number printed on the back of the member s ID card. To submit your request for any of the services below, contact AIM online via AIM s ProviderPortalsm at aimspecialtyhealth.com/goweb. From the drop-down menu, select GA. You may also call AIM toll-free at , Monday Friday, 8:00 a.m. 6:00 p.m. ET. AIM provides benefits management for the programs listed below: > Imaging Level of Care > Genetic Testing > Diagnostic Imaging Management > Cardiovascular Services > Radiation Therapy Services > Outpatient Sleep Testing and Therapy Services > Specialty Pharmacy Drugs > Cancer Care Quality Program > Musculoskeletal (MSK) Program (effective ) > Upper Gastrointestinal Endoscopy (effective 11/1/2018) For more details on these programs, please visit the AIM Specialty Health site at By clicking on the link above, you will be linked to sites created and/or maintained by another, separate entity ( External Site ). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. The information contained on the External Sites should not be interpreted as medical advice or treatment provided by us. New AIM Musculoskeletal (MSK) Program - Delay in launch for Fully Insured until June 4, 2018

2 The December 2017 edition of the Network Update announced that AIM Specialty Health (AIM), a separate company, would perform prior authorization reviews of certain surgeries of the spine and joints, as well as interventional pain treatment to determine medical necessity for fully insured BCBSGA members. Please be aware that this program has been delayed. We anticipate the new implementation date will be for requests received on and after June 4, The new musculoskeletal program includes review of the level of care/setting, pre-operative days, and expected length of stay for medical necessity using AIM clinical guidelines which have been adopted by BCBSGA. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website. If there are any additional delays to this program, we will publish notification to providers in a future Network Update. MED Selected Sleep Testing Services AIM Reviews AIM Reviews SURG SURG SURG Hip Resurfacing Percutaneous Neurolysis for Chronic Neck and Back Pain Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty S S AIM Reviews Delete

3 SURG SURG SURG SURG SURG SURG SURG Percutaneous and Endoscopic Spinal Surgery Lysis of Epidural Adhesions Implanted Devices for Spinal Stenosis Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis Bicompartmental Knee Arthroplasty Axial Lumbar Interbody Fusion Sacroiliac Joint Fusion Delete 0274T Delete 0275T Delete S2348 Delete T Delete C1821 Delete T S T Delete 0196T Delete 0309T Delete 27279

4 SURGERY SURGERY SURGERY Hip Replacement Shoulder Replacement Spinal Surgery Delete Delete Delete Delete Delete Delete S2350 Delete S2351 Delete

5 CG-DME-40 CG-DRUG-77 CG-MED-58 Electrical Bone Growth Stimulation Radium RA 223 Dichloride (Xofigo ) Coronary Artery Imaging: Contrast- Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI E0747 E0748 E A9606 DME DME Delete DME Delete DME DME Delete DRUG Moving to AIM 7/1/2018 DRUG Moving to AIM 7/1/2018 7/1/2018 7/1/ AIM reviews AIM reviews AIM reviews AIM reviews AIM reviews AIM reviews AIM reviews AIM reviews 0501T AIM reviews 0502T AIM reviews 0503T AIM reviews 0504T AIM reviews CG-MED-59 Upper Gastrointestinal Endoscopy Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/2018

6 CG-SURG-08 CG-SURG-32 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Pain Management: Cervical, Thoracic and Lumbar Facet Injections Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Will be reviewed by AIM 11/1/ Delete Delete L8680 Delete L8682 Delete L8684 Delete T Delete 0214T Delete

7 CG-SURG-33 CG-SURG-38 Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy T Delete 0216T Delete 0217T Delete 0218T Delete T Delete 0165T Delete

8 Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete CG-SURG-39 Pain Management: Epidural Steroid Injections T Delete 0229T Delete 0230T Delete 0231T Delete CG-SURG-42 Cervical Fusion Delete 22551

9 CG-SURG-43 Knee Arthroscopy Delete Delete Delete

10 CG-SURG-45 CG-SURG-47 CG-SURG-53 Bone Graft Substitutes Surgical Interventions for Scoliosis and Spinal Deformity Elective Total Hip Arthroplasty Delete G0289 Delete Delete

11 CG-SURG-54 Elective Total Knee Arthroplasty Delete CG-SURG-60 Cervical Total Disc Arthroplasty T Delete 0098T Delete 0375T Delete CG-SURG-65 Recombinant Human Bone Morphogenetic Protein SURG CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) SURG SURG SURG SURG Delete

12 CG-SURG-67 Treatment of Osteochondral Defects of the Knee and Ankle C1822 L8680 L8682 L8683 L8685 L8686 L8687 L SURG Delete SURG Delete SURG Delete SURG Delete SURG Delete SURG Delete SURG Delete SURG Delete SURG SURG SURG SURG Delete

13 CG-SURG-68 Surgical Treatment of Femoroacetabular Impingement Syndrome J7330 S SURG Delete SURG Delete SURG SURG SURG Delete SURG Delete SURG Delete SURG Delete SURG /27/2018 Add to pre-cert 3/1/2018 SURG.00109

14 CG-SURG-69 DME DME Meniscal Allograft Transplantation of the Knee Electrical Bone Growth Stimulation Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV) E0747 E0748 E0749 A7025 SURG TRANS Anthem Medical Policy or Clinical Guideline Content Transfers E0483 CG-DME-40. CG-DME-40. CG-DME-40. CG-DME-40. CG-DME-40. CG-DME-43 CG-DME-43

15 DME DRUG Automated Insulin Delivery Devices Radium RA 223 Dichloride (Xofigo ) E0784 S CG-DME-42 CG-DME-42 CG-DRUG-77. Moving to AIM 7/1/2018 A9606 CG-DRUG-77. Moving to AIM 7/1/2018 MED MED MED RAD Hyperhidrosis Manipulation Under Anesthesia of the Spine and Joints other than the Knee Cryopreservation of Oocytes or Ovarian Tissue Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule T 0357T CG-MED-63 CG-MED-63 CG-MED-63 CG-MED-63 CG-MED-63 CG-MED-65 CG-MED-66 CG-MED-66 CG-MED-66 CG-MED-66 CG-MED-66 CG-MED-66 CG-MED-66 CG-MED-70 CG-MED-70

16 SURG T Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement CG-MED-70 CG-MED-70 CG-SURG-76 SURG SURG Cryosurgical Ablation of Solid Tumors Outside the Liver Gastric Electrical Stimulation T 0076T T CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-61 CG-SURG-70

17 SURG SURG SURG Radiofrequency Ablation to Treat Tumors Outside the Liver Recombinant Human Bone Morphogenetic Protein Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) L8680 L CG-SURG-70 CG-SURG-70 CG-SURG-70 CG-SURG-70 CG-SURG-70 CG-SURG-70 CG-SURG-70 CG-SURG-62 CG-SURG-62 CG-SURG-62 CG-SURG-62 CG-SURG-65 CG-SURG-66 CG-SURG-66 CG-SURG-66

18 64999 C1822 L8680 L8682 L8683 L8685 L8686 L8687 L8688 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 CG-SURG-66 Delete

19 SURG SURG Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies CG-SURG-63 CG-SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG- SURG-63 CG-SURG-78 SURG Implantable Infusion Pumps CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-79

20 SURG SURG SURG SURG Total Ankle Replacement Reduction Mammaplasty Self-Expanding Absorptive Sinus Ostial Dilation Treatment of Osteochondral Defects of the Knee and Ankle C CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-74 CG-SURG-71 CG-SURG-71 Some content transferred to CG-SURG-73 Some content transferred to CG-SURG-73 Some content transferred to CG-SURG-73 Add Some content transferred to CG-SURG-73 Add Some content transferred to CG-SURG-73 CG-SURG-67

21 CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-67

22 SURG TRANS CG-DME-01 Surgical Treatment of Femoroacetabular Impingement Syndrome Meniscal Allograft Transplantation of the Knee External (Portable) Continuous Insulin Infusion Pumps J7330 S A9274 E0784 GA Standard Preapproval Code List CG-SURG-67 CG-SURG-67 CG-SURG-67 CG-SURG-68 Add to pre-cert 3/1/2018 CG-SURG-68 Add to pre-cert 3/1/2018 CG-SURG-68 Add to pre-cert 3/1/2018 CG-SURG-69. CG-DME-42 CG-DME-42

23 DRG / Medical Policy / Clinical Guideline Number DRG 219, 220 Cardiac Valve Replacement or Repair Name Code Change Effective Date Aortic Aneurysm, Thoracic, Repair with Graft Aortic Coarctation, Excision or Repair Cardiac Valve: Ross Procedure 33413

24 DRG 329, 330 ANC Bowel Surgery: Colectomy, Partial, with or without Ostomy Bowel Surgery: Abdominoperineal Resection or Total Colectomy with Proctectomy Bowel Surgery: Colectomy, Partial, with or without Ostomy, by Laparoscopy Bowel Surgery: Small Intestine Resection Intussusception Reduction, Surgical Cosmetic and Reconstructive Services: Skin Related

25 ANC Cosmetic and Reconstructive Services of the Head and Neck J

26 ANC Cosmetic and Reconstructive Services of the Trunk and Groin

27 BEH DME Transcranial Magnetic Stimulation for Depression Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) E0745 E0764 E0770 DME Transtympanic Micropressure for the Treatment of Ménière s Disease E2120 DME Ultrasound Bone Growth Stimulation E0760 DME Standing Frames E0638 E0641 E0642 E2301 DME Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices E1801 E1806 E1811 E1816 E1818 E1821 E1831 E1841 E1399 DRUG Chelation Therapy J0470 J0600 J0895 J3520 M0300 S9355 DRUG NOTE: For drugs NOT listed below, please check the AIM website at aimspecialtyhealth.com/goweb Subcutaneous Hormone Replacement Implants J3490

28 MED MED MED Hyperbaric Oxygen Therapy (Systemic/Topical) Prolotherapy for Joint and Ligamentous Conditions Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry S G0277 M C1764 E0616 MED Wearable Cardioverter Defibrillators K0606 MED MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications C9734 C T 0072T 0398T MED Antineoplaston Therapy J3490 J8499 J8999 J9999 MED MED MED OR-PR Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management Near-Infrared Spectroscopy Brain Screening for Hematoma Detection Microprocessor Controlled Lower Limb Prosthesis C2624 C L5856 L5857 L5858 L5859

29 OR-PR RAD SURG Powered Robotic Lower Body Exoskeleton Devices Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule L T Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement T 0076T SURG Partial Left Ventriculectomy SURG Vagus Nerve Stimulation E1399 L8680 L8685 L8686 SURG Cochlear Implants and Auditory Brainstem Implants L8614 L8619 CG-MED-70 CG-MED-70 CG-MED-70 CG-MED-70 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76 CG-SURG-76

30 SURG Bone-Anchored and Bone Conduction Hearing Aids L8627 L8628 S L8690 L8691 L8694 Add V5298 SURG Lung Volume Reduction Surgery SURG Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures C1789 L8600 S2066 S2067 S2068

31 SURG Bariatric Surgery and Other Treatments for Clinically Severe Obesity T 0313T 0314T 0315T 0316T 0317T SURG Deep Brain Stimulation C1767 C1820 C1822 L8680 L8682 L8683 L8685 L8686

32 SURG Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions L8687 L SURG Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention C9748 Add SURG Cardioverter-Defibrillators C1721 C1722 C1777 C1882 C1895 C1896 SURG Treatment of Varicose Veins (Lower Extremities) Add Add

33 SURG SURG Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons Extracorporeal Shock Wave Therapy for Orthopedic Conditions Add 9/1/ Add 9/1/ S2202 S T 0102T SURG Panniculectomy and Abdominoplasty SURG Mandibular/Maxillary (Orthognathic) Surgery

34 SURG SURG SURG D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7995 D7996 Presbyopia and Astigmatism-Correcting V2788 Intraocular Lenses Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies CG-SURG-78 SURG Implantable Infusion Pumps CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-78 CG-SURG-79 CG-SURG-79

35 SURG Photocoagulation of Macular Drusen SURG Epiduroscopy SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA) SURG SURG Total Ankle Replacement Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 CG-SURG-79 C9749 Add 9/1/ CG-SURG Delete - always deny 0054T Delete - always deny 0055T Delete - always deny SURG Implantable Middle Ear Hearing Aids S2230 SURG Mastectomy for Gynecomastia 15877

36 SURG Self-Expanding Absorptive Sinus Ostial Dilation Some content transferred to CG-SURG-73 Some content transferred to CG-SURG-73 Some content transferred to CG-SURG-73 Add Some content transferred to CG-SURG Add C1726 SURG Viscocanalostomy and Canaloplasty SURG Surgical and Ablative Treatments for Chronic Headaches SURG Cryoablation for Plantar Fasciitis and Plantar Fibroma SURG Suprachoroidal Injection of a Pharmacologic Agent 0465T SURG Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) SURG Ablative Techniques as a Treatment for Barrett's Esophagus 0191T 0253T 0376T 0449T 0450T 0474T Add Some content transferred to CG-SURG SURG Occiptal nerve stimulation Add 7/1/ L8679 L8680 L8685 L8686 SURG Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects 33999

37 SURG SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography T 0467T 0468T C9727 S T 0352T 0353T 0354T SURGERY Gallbladder Removal SURGERY Hysterectomy

38 CG-ANC-06 CG-BEH-02 Ambulance Services: Ground; Non- Emergent Applied Behavioral Analysis for Autism Spectrum Disorder A0380 A0390 A0425 A0426 A0428 A0432 A T 0360T 0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T 0369T

39 CG-BEH-14 Intensive In-home Behavioral Health Services 0370T 0371T 0372T 0373T 0374T H0020 H0031 H0032 H0046 H2012 H2014 H2019 H0004 H0006 H0023 H0036 H2015 H2019 H2020 CG-DME-06 Pneumatic Pressure Devices E0652 CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) E1399 Add 9/1/2018 E1902 E2351 E2500 E2502 E2504 E2506 E2508 E2510 E1002 E1006 E1007 E1009 E1010 E1012 E1230 E1239

40 E2300 K0010 K0011 K0012 K0013 K0014 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

41 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899 CG-DME-33 Wheeled Mobility Devices: Manual K0005 Wheelchairs Ultra Lightweight CG-DME-35 Electric Breast Pumps E0603 Delete 4/16/2018 E0604 CG-DME-42 Non-implantable Insulin Infusion and Blood E0784 Glucose Monitoring Devices DME S1034 DME A9274 CG-DME-01 E0784 CG-DME-01 CG-DME-43 Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV) A7025 DME.00012

42 E0483 DME NOTE: For drugs NOT listed below, please check the AIM website at aimspecialtyhealth.com/goweb CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home C9113 Delete 6/1/2018 Setting J0744 Delete 6/1/2018 J1450 Delete 6/1/2018 J1956 Delete 6/1/2018 J2020 Delete 6/1/2018 J2280 Delete 6/1/2018 S0030 Delete 6/1/2018 S0039 Delete 6/1/2018 S0164 Delete 6/1/2018 DRUG Injection, alemtuzumab, 10 mg J9010 DRUG Injection, aldesleukin, per single use vial J9015 DRUG Injection, topotecan, 0.1 mg J9351 CG-LAB-03 Tropism Testing for HIV Management CG-MED-02 Esophageal ph Monitoring CG-MED-29 Inpatient Sub-acute Care Delete - Replaced by 0190 Milliman Care Guidelines 3/1/ Delete - Replaced by Milliman Care Guidelines 3/1/ Delete - Replaced by Milliman Care Guidelines 3/1/ Delete - Replaced by Milliman Care Guidelines 3/1/ Delete - Replaced by Milliman Care Guidelines 3/1/ Delete - Replaced by Milliman Care Guidelines 3/1/2018 CG-MED-31 Skilled Nursing Facility Services Delete - Replaced by 0022 Milliman Care Guidelines 3/1/2018 CG-MED-37 Intensive Programs for Pediatric Feeding See Guidelines CG-MED-46 Disorders Ambulatory and Inpatient Video Electroencephalography

43 CG-MED-63 CG-MED-65 CG-MED-66 CG-MED-70 CG-OR-PR-05 Hyperhidrosis Manipulation Under Anesthesia of the Spine and Joints other than the Knee Cryopreservation of Oocytes or Ovarian Tissue Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule Myoelectric Upper Extremity Prosthetic Devices (previously CG-DME-28) T 0357T T L6611 L6677 L6880 L6881 L6882 L6925 MED MED MED MED MED MED MED MED MED MED MED MED MED RAD RAD RAD RAD.00030

44 CG-REHAB-08 Private Duty Nursing in the Home Setting L6935 L6945 L6955 L6965 L6975 L7007 L7008 L7009 L7045 L7180 L7181 L7190 L7191 S9123 CG-REHAB-09 CG-SURG-03 Acute Inpatient Rehabilitation Blepharoplasty, Blepharoptosis Repair and Brow Lift S9124 T1000 T1002 T1003 T1030 T Delete - Replaced by Milliman Care Guidelines Delete - Replaced by Milliman Care Guidelines Delete - Replaced by Milliman Care Guidelines Delete - Replaced by Milliman Care Guidelines Delete - Replaced by Milliman Care Guidelines 3/1/2018 3/1/2018 3/1/2018 3/1/2018 3/1/2018

45 CG-SURG-05 Maze Procedure CG-SURG-09 Temporomandibular Disorders D7810 D7820 D7830 D7840 D7850 D7852 D7854 D7856 D7858 D7860 D7865 D7870 D7871 D7873 D7874 D7875 D7876 D7877 D7880 D9940 D9950 D9951 D9952 CG-SURG-12 Penile Prosthesis Implantation 54400

46 CG-SURG-18 Septoplasty CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Add Add Add S2342 CG-SURG-27 Gender Reassignment Surgery

47 CG-SURG-28 Transcatheter Uterine Artery Embolization CG-SURG-30 Tonsillectomy with or without Adenoidectomy for Children CG-SURG-34 Diagnostic Infertility Surgery CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) CG-SURG-36 Adenoidectomy CG-SURG-59 Vena Cava Filters Add 7/1/ Add 7/1/2018 CG-SURG-61 CG-SURG-62 Cryosurgical Ablation of Solid Tumors Outside the Liver Radiofrequency Ablation to Treat Tumors Outside the Liver Add 7/1/ SURG SURG SURG SURG SURG SURG SURG T SURG SURG SURG SURG SURG.00050

48 CG-SURG-63 CG-SURG-68 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Surgical Treatment of Femoroacetabular Impingement Syndrome SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG /27/2018 Add to pre-cert 3/1/2018 SURG /27/2018 Add to pre-cert 3/1/2018

49 CG-SURG-70 CG-SURG-71 CG-SURG-73 CG-SURG-74 Gastric Electrical Stimulation Reduction Mammaplasty Self-Expanding Absorptive Sinus Ostial Dilation Total Ankle Replacement SURG /27/2018 Add to pre-cert 3/1/ SURG SURG SURG SURG SURG SURG L8680 SURG L8688 SURG SURG SURG SURG SURG SURG Add SURG Add Add C1726 SURG SURG.00081

50 CG-SURG-76 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement Content trasferred from SURG CG-SURG T 0076T Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG Content trasferred from SURG SURG CG-SURG-79 Implantable Infusion Pumps SURG SURG SURG SURG SURG SURG SURG SURG SURG.00068

51 CG-TRANS-02 Kidney Transplantation SURG SURG SURG SURG SURG SURG.00068