Experimental and investigational procedure codes Following are updated experimental and investigational procedure codes and associated supporting policies effective January 1, 2018. Procedure codes 0001M 0002M 0003M 0004M 0008M 0019T 0042T 0054T 0055T 0057T 0058T 0071T 0072T 0075T 0076T 0085T 0100T 0101T 0102T 0106T 0107T 0108T Supporting policy LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions RAD.00045 Cerebral Perfusion Imaging Using Computed Tomography SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System MED.00080 Cryopreservation of Oocytes or Ovarian Tissue MED.00080 Cryopreservation of Oocytes or Ovarian Tissue MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection SURG.00113 Artificial Retinal Devices SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions MED.00082 Quantitative Sensory Testing MED.00082 Quantitative Sensory Testing MED.00082 Quantitative Sensory Testing https://providers.amerigroup.com/ia IAPEC-0895-18 April 2018
0109T 0110T 0163T 0165T 0169T 0171T 0172T 0182T 0190T 0195T 0196T 0200T 0201T 0202T 0205T 0206T 0207T 0219T 0220T 0221T 0222T 0232T 0233T 0249T 0253T 0263T 0264T 0265T 0266T 0267T 0268T 0269T 0270T 0271T 0272T 0273T MED.00082 Quantitative Sensory Testing MED.00082 Quantitative Sensory Testing SURG.00055 Cervical Artificial Intervertebral Discs SURG.00055 Cervical Artificial Intervertebral Discs SURG.00099 Convection-Enhanced Delivery of Therapeutic Agents to the Brain SURG.00092 Implanted Devices for Spinal Stenosis SURG.00092 Implanted Devices for Spinal Stenosis RAD.00014 Brachytherapy for Oncologic Indications RAD.00056 Intraocular Epiretinal Brachytherapy SURG.00111 Axial Lumbar Interbody Fusion SURG.00111 Axial Lumbar Interbody Fusion SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty SURG.00092 Implanted Devices for Spinal Stenosis RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging MED.00074 Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data MED.00103 Automated Evacuation of Meibomian Gland SURG.00114 Facet Joint Allograft Implants for Facet Disease SURG.00114 Facet Joint Allograft Implants for Facet Disease SURG.00114 Facet Joint Allograft Implants for Facet Disease SURG.00114 Facet Joint Allograft Implants for Facet Disease MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting MED.00104 Noninvasive Measurement of Advanced Glycation End products (AGEs) in the Skin SURG.00141 Doppler-Guided Transanal Hemorrhoidal Deaterialization SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices Page 2 of 16
0274T 0275T 0281T 0282T 0283T 0284T 0285T 0288T 0291T 0292T 0293T 0294T 0301T 0302T 0303T 0304T 0305T 0306T 0307T 0309T 0312T 0313T 0314T 0315T 0316T 0317T 0328T 0329T 0330T 0331T 0332T 0335T 0336T SURG.00071 Percutaneous and Endoscopic Spinal Surgery SURG.00071 Percutaneous and Endoscopic Spinal Surgery SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence RAD.00062 Intravascular Optical Coherence Tomography (OCT) RAD.00062 Intravascular Optical Coherence Tomography (OCT) SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor SURG.00137 Focused Microwave Therotherapy for Breast Cancer MED.00111 Intracardiac Ischemia Monitoring MED.00111 Intracardiac Ischemia Monitoring MED.00111 Intracardiac Ischemia Monitoring MED.00111 Intracardiac Ischemia Monitoring MED.00111 Intracardiac Ischemia Monitoring MED.00111 Intracardiac Ischemia Monitoring SURG.00111 Axial Lumbar Interbody Fusion SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00033 Implantable Cardioverter-Defibrillator (ICD) MED.00118 Continuous Monitoring of Intraocular Pressure MED.00103 Automated Evacuation of Meibomian Gland RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single- Photon Emission Computed Tomography (SPECT) RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single- Photon Emission Computed Tomography (SPECT) SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques Page 3 of 16
0338T 0339T 0340T 0342T 0345T 0347T 0348T 0349T 0350T SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver MED.00113 Therapeutic Apheresis SURG.00121 Transcatheter Heart Valve Procedures RAD.00065 Radiostereometric Analysis (RSA) RAD.00065 Radiostereometric Analysis (RSA) RAD.00065 Radiostereometric Analysis (RSA) RAD.00065 Radiostereometric Analysis (RSA) 0351T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast- Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0352T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0353T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast- Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0354T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast- Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0357T 0375T 0380T 0392T 0393T 0394T 0395T 0397T 0402T 0423T 0424T 0425T 0426T 0427T 0428T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue SURG.00055 Cervical Artificial Intervertebral Discs CG-MED-47 Fundus Photography SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD) SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD) THER-RAD.00001 Brachytherapy for Oncologic Indications THER-RAD.00001 Brachytherapy for Oncologic Indications MED.00077 In-Vivo Analysis of Gastrointestinal Lesions MED.00109 Corneal Collagen Cross-Linking LAB.00031 Advanced Lipoprotein Testing Page 4 of 16
0429T 0430T 0431T 0432T 0433T 0434T 0435T 0436T 0438T SURG.00143 SpaceOAR System 15775 ANC.00007 Cosmetic and Reconstructive Services: Skin Related 15776 ANC.00007 Cosmetic and Reconstructive Services: Skin Related 15783 ANC.00007 Cosmetic and Reconstructive Services: Skin Related 15819 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck 15825 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck 15826 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck 15829 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck 15837 ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin 15838 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck 15839 ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin 15847 SURG.00048 Panniculectomy and Abdominoplasty 15876 MED.00032 Treatment of Hyperhidrosis 15878 MED.00032 Treatment of Hyperhidrosis 15879 MED.00032 Treatment of Hyperhidrosis 19105 SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver 20983 SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver 20985 SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System 21811 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation 21812 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation 21813 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation 22526 SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy IDET, Percutaneous Intradiscal Radiofrequency Thermocoagulation PIRFT and Intradiscal Biacuplasty IDB) Page 5 of 16
22527 SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy IDET, Percutaneous Intradiscal Radiofrequency Thermocoagulation PIRFT and Intradiscal Biacuplasty IDB) 22586 SURG.00111 Axial Lumbar Interbody Fusion 24300 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee 25259 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee 26340 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee 27275 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee 27279 SURG.00127 Sacroiliac Joint Fusion 27860 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee 28446 SURG.00093 Treatment of Osteochondral Defects 28890 SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions 31295 SURG.00089 Balloon Sinus Ostial Dilation 31296 SURG.00089 Balloon Sinus Ostial Dilation 31297 SURG.00089 Balloon Sinus Ostial Dilation 31627 MED.00099 Electromagnetic Navigational Bronchoscopy 31647 SURG.00119 Endobronchial Valve Devices 31648 SURG.00119 Endobronchial Valve Devices 31649 SURG.00119 Endobronchial Valve Devices 31651 SURG.00119 Endobronchial Valve Devices 31660 SURG.00118 Bronchial Thermoplasty 31661 SURG.00118 Bronchial Thermoplasty 33418 SURG.00121 Transcatheter Heart Valve Procedures 33419 SURG.00121 Transcatheter Heart Valve Procedures 33548 SURG.00005 Partial Left Ventriculectomy 33990 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) 33991 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) 33992 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) 33993 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) 34839 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34841 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Page 6 of 16
34842 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34843 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34844 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34845 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34846 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34847 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 34848 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac 36468 SURG.00037 Treatment of Varicose Veins (Lower Extremities), ANC.00007 Cosmetic and Reconstructive Services: Skin Related 41512 SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea 43206 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions 43210 SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia 43252 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions 43257 SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease 46707 46762 SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence 52441 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions 52442 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions 53855 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions 53860 SURG.00010 Treatments for Urinary Incontinence 55706 SURG.00107 Prostate Saturation Biopsy 61630 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement 61640 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement 61641 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement Page 7 of 16
61642 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement 61870 SURG.00026 Deep Brain Stimulation 62263 SURG.00072 Lysis of Epidural Adhesions 62264 SURG.00072 Lysis of Epidural Adhesions 62287 SURG.00071 Percutaneous and Endoscopic Spinal Surgery 62291 RAD.00053 Cervical and Thoracic Discography 64566 SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention 65760 SURG.00009 Refractive Surgery 65765 SURG.00009 Refractive Surgery 65771 SURG.00009 Refractive Surgery 66174 SURG.00095 Viscocanalostomy and Canaloplasty 66175 SURG.00095 Viscocanalostomy and Canaloplasty 69090 ANC.0008 Cosmetic and Reconstructive Services of the Head and Neck 72285 RAD.00053 Cervical and Thoracic Discography 75571 RAD.00001 Computed Tomography to Detect Coronary Artery Calcification 76977 RAD.00004 Peripheral Bone Mineral Density Measurement 77084 RAD.00054 MRI of the Bone Marrow 77422 THER-RAD.00008 Neutron Beam Radiotherapy 77423 THER-RAD.00008 Neutron Beam Radiotherapy 77605 MED.00026 Hyperthermia for Cancer Therapy 77620 MED.00026 Hyperthermia for Cancer Therapy 78350 RAD.00004 Peripheral Bone Mineral Density Measurement 78647 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications 81227 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug- Metabolizer Status 81240 GENE.00046 Prothrombin G20210A (Factor II) Mutation Testing 81291 GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing 81313 GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer 81324 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies 81325 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies 81326 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies 81350 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug- Metabolizer Status 81355 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug- Metabolizer Status 81410 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81411 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases Page 8 of 16
81415 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81416 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81417 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81425 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81426 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81427 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81430 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81431 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81435 GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility 81436 GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility 81437 GENE.00001 Genetic Testing for Cancer Susceptibility 81438 GENE.00001 Genetic Testing for Cancer Susceptibility 81440 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81445 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors, GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome, GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility, GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome) 81450 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors 81455 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors, GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome, GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility, GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome) 81460 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81465 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81470 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81471 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases 81504 GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site 81506 GENE.00015 Predictive Genetic Testing for Non-Malignant Diseases 81525 GENE.00016 Gene Expression Profiling for Colorectal Cancer 81538 LAB.00011 Analysis of Proteomic Patterns 81540 GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site 82172 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management 83695 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management 83698 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management 83700 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management Page 9 of 16
83701 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management 83704 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management 84112 LAB.00029 Rupture of Membranes (ROM) Testing in Pregnancy 86001 LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests 86152 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer 86153 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer 86343 LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests 86352 LAB.00024 Immune Cell Function Assay 88375 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions 90672 ADMIN.00007 Immunizations 91111 RAD.00030 Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule 91112 MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders 92132 MED.00095 Anterior Segment Optical Coherence Tomography 93025 MED.00041 Microvolt T-Wave Alternans 93702 MED.000105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema 95803 MED.00002 Selected Sleep Testing Services 95905 MED.00092 Automated Nerve Conduction Testing 95921 MED.00112 Autonomic Testing 95922 MED.00112 Autonomic Testing 95923 MED.00112 Autonomic Testing 95924 MED.00112 Autonomic Testing 95943 MED.00112 Autonomic Testing 96904 MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography) 97610 MED.00096 Low-Frequency Ultrasound Therapy for Wound Management A4575 A4638 A9272 A9507 A9527 A9584 A9586 MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical) DME.00024 Transtympanic Micropressure for the Treatment of Ménière s Disease DME.00009 Vacuum-Assisted Wound Therapy in the Outpatient Setting RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications THER-RAD.00001 Brachytherapy for Oncologic Indications RAD.00023 Single Photon Emission-Computed Tomography (SPECT) Scans for Noncardiovascular Indications RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion Page 10 of 16
A9599 C1821 C1841 C2624 C9349 C9352 C9353 C9354 C9355 C9356 C9358 C9360 C9361 C9364 C9458 C9459 C9461 C9472 C9739 C9740 C9741 E0218 E0236 E0481 E0485 E0617 E0637 E0638 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion SURG.00092 Implanted Devices for Spinal Stenosis SURG.00113 Artificial Retinal Devices MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion MED.00083 Melanoma Vaccines SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management DME.00037 Cooling Devices and Combined Cooling/Heating Devices DME.00037 Cooling Devices and Combined Cooling/Heating Devices DME.00012 Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV) DME.00039 Prefabricated Oral Appliance for the Treatment of Obstructive Sleep Apnea DME.00032 Automated External Defibrillators for Home Use DME.00034 Standing Frames DME.00034 Standing Frames Page 11 of 16
E0641 E0642 E0762 E0764 E0770 E1801 E1806 E1811 E1816 E1818 E1821 E1831 E1841 E2120 E2230 E2301 G0130 G0219 G0252 G0255 G0341 G0342 G0343 DME.00034 Standing Frames DME.00034 Standing Frames DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices DME.00024 Transtympanic Micropressure for the Treatment of Ménière s Disease DME.00034 Standing Frames DME.00034 Standing Frames RAD.00004 Peripheral Bone Mineral Density Measurement RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion MED.00082 Quantitative Sensory Testing TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation G0428 G0460 MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting G9143 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug- Metabolizer Status G9147 MED.00065 Hepatic Activation Therapy L5973 L6026 OR PR.00003 Microprocessor Controlled Lower Limb Prosthesis OR PR.0004 Myoelectric Upper Extremity Prosthetic Devices Page 12 of 16
L6715 L8607 M0075 M0076 Q4102 Q4103 Q4105 Q4107 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4117 Q4118 Q4119 Q4120 Q4122 Q4123 Q4124 Q4125 Q4126 Q4127 OR PR.00004 Partial-Hand Myoelectric Prosthesis MED.00024 Adoptive Immunotherapy and Cellular Therapy MED.00007 Prolotherapy for Joint and Ligamentous Conditions Page 13 of 16
Q4129 Q4130 Q4132 Q4133 Q4134 Q4135 Q4136 Q4137 Q4138 Q4139 Q4140 Q4141 Q4142 Q4143 Q4145 Q4146 Q4147 Q4148 Q4149 Q4150 Q4151 Q4152 Q4153 Page 14 of 16
Q4154 Q4155 Q4156 Q4157 Q4158 Q4159 Q4160 Q4161 Q4162 Q4163 Q4164 Q4165 S0596 S1090 S2102 S2103 S2107 S2117 S2230 S2300 S2348 S2400 S3721 S3800 S3852 S3861 S3865 SURG.00009 Refractive Surgery SURG.00132 Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) MED.00024 Adoptive Immunotherapy and Cellular Therapy SURG.00104 Subtalar Arthroereisis SURG.00084 Implantable Middle Ear Hearing Aids SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons SURG.00071 Percutaneous and Endoscopic Spinal Surgery SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer GENE.00013 Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease GENE.00007 Cardiac Ion Channel Genetic Testing GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C) Page 15 of 16
S3890 S8040 S8080 S8085 S8130 S8131 S8930 S8940 S9024 S9055 S9056 S9090 V2787 V2788 V5095 GENE.00008 Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance MED.00002 Selected Sleep Testing Services RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications RAD.00040 PET Scanning Using Gamma Cameras DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices REHAB.00003 Hippotherapy RAD.00012 Ultrasound for the Evaluation of Paranasal Sinuses MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State SURG.00008 Mechanized Spinal Distraction Therapy for Low Back Pain (VAX-D Therapy, DRS System, Accu-Spina System IDD Therapy) SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses SURG.00084 Implantable Middle Ear Hearing Aids Page 16 of 16