experimental and investigational procedure codes · 0054t surg.00082 computer-assisted...
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IAPEC-0895-18 April 2018
Experimental and investigational procedure codes
Following are updated experimental and investigational procedure codes and associated supporting policies effective January 1, 2018.
Procedure codes
Supporting policy
0001M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
0002M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
0003M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
0004M GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis
0008M GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment
0019T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
0042T RAD.00045 Cerebral Perfusion Imaging Using Computed Tomography
0054T SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
0055T SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
0057T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue
0058T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue
0071T MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids
0072T MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids
0075T SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
0076T SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
0085T TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
0100T SURG.00113 Artificial Retinal Devices
0101T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
0102T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
0106T MED.00082 Quantitative Sensory Testing
0107T MED.00082 Quantitative Sensory Testing
0108T MED.00082 Quantitative Sensory Testing
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0109T MED.00082 Quantitative Sensory Testing
0110T MED.00082 Quantitative Sensory Testing
0163T SURG.00055 Cervical Artificial Intervertebral Discs
0165T SURG.00055 Cervical Artificial Intervertebral Discs
0169T SURG.00099 Convection-Enhanced Delivery of Therapeutic Agents to the Brain
0171T SURG.00092 Implanted Devices for Spinal Stenosis
0172T SURG.00092 Implanted Devices for Spinal Stenosis
0182T RAD.00014 Brachytherapy for Oncologic Indications
0190T RAD.00056 Intraocular Epiretinal Brachytherapy
0195T SURG.00111 Axial Lumbar Interbody Fusion
0196T SURG.00111 Axial Lumbar Interbody Fusion
0200T SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
0201T SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
0202T SURG.00092 Implanted Devices for Spinal Stenosis
0205T RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
0206T MED.00074 Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
0207T MED.00103 Automated Evacuation of Meibomian Gland
0219T SURG.00114 Facet Joint Allograft Implants for Facet Disease
0220T SURG.00114 Facet Joint Allograft Implants for Facet Disease
0221T SURG.00114 Facet Joint Allograft Implants for Facet Disease
0222T SURG.00114 Facet Joint Allograft Implants for Facet Disease
0232T MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
0233T MED.00104 Noninvasive Measurement of Advanced Glycation End products (AGEs) in the Skin
0249T SURG.00141 Doppler-Guided Transanal Hemorrhoidal Deaterialization
0253T SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
0263T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease
0264T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease
0265T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease
0266T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0267T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0268T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0269T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0270T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0271T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0272T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
0273T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
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0274T SURG.00071 Percutaneous and Endoscopic Spinal Surgery
0275T SURG.00071 Percutaneous and Endoscopic Spinal Surgery
0281T SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
0282T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
0283T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
0284T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
0285T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
0288T SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
0291T RAD.00062 Intravascular Optical Coherence Tomography (OCT)
0292T RAD.00062 Intravascular Optical Coherence Tomography (OCT)
0293T SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor
0294T SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor
0301T SURG.00137 Focused Microwave Therotherapy for Breast Cancer
0302T MED.00111 Intracardiac Ischemia Monitoring
0303T MED.00111 Intracardiac Ischemia Monitoring
0304T MED.00111 Intracardiac Ischemia Monitoring
0305T MED.00111 Intracardiac Ischemia Monitoring
0306T MED.00111 Intracardiac Ischemia Monitoring
0307T MED.00111 Intracardiac Ischemia Monitoring
0309T SURG.00111 Axial Lumbar Interbody Fusion
0312T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0313T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0314T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0315T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0316T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0317T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
0328T SURG.00033 Implantable Cardioverter-Defibrillator (ICD)
0329T MED.00118 Continuous Monitoring of Intraocular Pressure
0330T MED.00103 Automated Evacuation of Meibomian Gland
0331T RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
0332T RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
0335T SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
0336T SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
Page 4 of 16
0338T SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
0339T SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
0340T SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver
0342T MED.00113 Therapeutic Apheresis
0345T SURG.00121 Transcatheter Heart Valve Procedures
0347T RAD.00065 Radiostereometric Analysis (RSA)
0348T RAD.00065 Radiostereometric Analysis (RSA)
0349T RAD.00065 Radiostereometric Analysis (RSA)
0350T 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 MED.00080 Cryopreservation of Oocytes or Ovarian Tissue
0375T SURG.00055 Cervical Artificial Intervertebral Discs
0380T CG-MED-47 Fundus Photography
0392T SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
0393T SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
0394T THER-RAD.00001 Brachytherapy for Oncologic Indications
0395T THER-RAD.00001 Brachytherapy for Oncologic Indications
0397T MED.00077 In-Vivo Analysis of Gastrointestinal Lesions
0402T MED.00109 Corneal Collagen Cross-Linking
0423T LAB.00031 Advanced Lipoprotein Testing
0424T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0425T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0426T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0427T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0428T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
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0429T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0430T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0431T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0432T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0433T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0434T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0435T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
0436T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
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)
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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 Disease, Aortic Dissection and Aortic Transection
34841 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
Page 7 of 16
34842 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34843 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34844 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34845 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34846 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34847 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
34848 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
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 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
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 8 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 9 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 10 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 MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical)
A4638 DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease
A9272 DME.00009 Vacuum-Assisted Wound Therapy in the Outpatient Setting
A9507 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
A9527 THER-RAD.00001 Brachytherapy for Oncologic Indications
A9584 RAD.00023 Single Photon Emission-Computed Tomography (SPECT) Scans for Noncardiovascular Indications
A9586 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
Page 11 of 16
A9599 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
C1821 SURG.00092 Implanted Devices for Spinal Stenosis
C1841 SURG.00113 Artificial Retinal Devices
C2624 MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
C9349 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9352 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9353 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9354 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9355 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9356 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9358 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9360 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9361 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9364 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
C9458 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
C9459 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
C9461 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
C9472 MED.00083 Melanoma Vaccines
C9739 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
C9740 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
C9741 MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
E0218 DME.00037 Cooling Devices and Combined Cooling/Heating Devices
E0236 DME.00037 Cooling Devices and Combined Cooling/Heating Devices
E0481 DME.00012 Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV)
E0485 DME.00039 Prefabricated Oral Appliance for the Treatment of Obstructive Sleep Apnea
E0617 DME.00032 Automated External Defibrillators for Home Use
E0637 DME.00034 Standing Frames
E0638 DME.00034 Standing Frames
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E0641 DME.00034 Standing Frames
E0642 DME.00034 Standing Frames
E0762 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
E0764 DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
E0770 DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
E1801 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1806 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1811 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1816 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1818 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1821 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1831 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E1841 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
E2120 DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease
E2230 DME.00034 Standing Frames
E2301 DME.00034 Standing Frames
G0130 RAD.00004 Peripheral Bone Mineral Density Measurement
G0219 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
G0252 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
G0255 MED.00082 Quantitative Sensory Testing
G0341 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
G0342 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
G0343 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
G0428 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
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 OR PR.00003 Microprocessor Controlled Lower Limb Prosthesis
L6026 OR PR.0004 Myoelectric Upper Extremity Prosthetic Devices
Page 13 of 16
L6715 OR PR.00004 Partial-Hand Myoelectric Prosthesis
L8607 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
M0075 MED.00024 Adoptive Immunotherapy and Cellular Therapy
M0076 MED.00007 Prolotherapy for Joint and Ligamentous Conditions
Q4102 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4103 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4105 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4107 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4108 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4110 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4111 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4112 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4113 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4114 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4117 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4118 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4119 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4120 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4122 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4123 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4124 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4125
SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4126 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4127 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Page 14 of 16
Q4129 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4130 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4132 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4133 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4134 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4135 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4136 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4137 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4138 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4139 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4140 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4141 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4142 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4143 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4145 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4146 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4147 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4148 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4149 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4150 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4151 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4152 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4153 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Page 15 of 16
Q4154 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4155 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4156 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4157 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4158 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4159 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4160 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4161 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4162 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4163 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4164 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Q4165 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
S0596 SURG.00009 Refractive Surgery
S1090 SURG.00132 Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery
S2102 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
S2103 TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
S2107 MED.00024 Adoptive Immunotherapy and Cellular Therapy
S2117 SURG.00104 Subtalar Arthroereisis
S2230 SURG.00084 Implantable Middle Ear Hearing Aids
S2300 SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
S2348 SURG.00071 Percutaneous and Endoscopic Spinal Surgery
S2400 SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
S3721 GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
S3800 GENE.00013 Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child)
S3852 GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
S3861 GENE.00007 Cardiac Ion Channel Genetic Testing
S3865 GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)
Page 16 of 16
S3890 GENE.00008 Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance
S8040 MED.00002 Selected Sleep Testing Services
S8080 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
S8085 RAD.00040 PET Scanning Using Gamma Cameras
S8130 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
S8131 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
S8930 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
S8940 REHAB.00003 Hippotherapy
S9024 RAD.00012 Ultrasound for the Evaluation of Paranasal Sinuses
S9055 MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
S9056 MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
S9090 SURG.00008 Mechanized Spinal Distraction Therapy for Low Back Pain (VAX-D® Therapy, DRS® System, Accu-Spina System™ IDD Therapy)
V2787 SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
V2788 SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
V5095 SURG.00084 Implantable Middle Ear Hearing Aids
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