PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHPRadiology MRI 70336 MRI TMJ Tempomandibular joint/jaw PA Medical Necessity Review
Radiology CT SCANS 70450 CT Head/Brain w/o Contrast PA Medical Necessity Review
Radiology CT SCANS 70470 CT Head/Brain w/o & w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 70480 CT Orbit w/o Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review
Radiology CT SCANS 70481 CT Orbit w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review
Radiology CT SCANS 70482 CT Orbit w/o & w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review
Radiology CT SCANS 70486 CT Maxllfcl w/o Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review
Radiology CT SCANS 70487 CT Maxllfcl w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review
Radiology CT SCANS 70488 CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology CT SCANS 70488 CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review
Radiology CT SCANS 70490 CT Soft Tissue Neck w/o Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review
Radiology CT SCANS 70491 CT Soft Tissue Neck w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review
Radiology CT SCANS 70492 CT Soft Tissue Neck w/o & w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review
Radiology CT SCANS 70496 Ct Angiography Head PA Medical Necessity Review
Radiology CT SCANS 70498 Ct Angiography Neck PA Medical Necessity Review
Radiology MRI 70540 MRI Face, Orbit, Neck w/o Contrast Sinus/3 areas (soft tissue neck) eyes/temporal PA Medical Necessity Review
Radiology MRI 70542 MRI Face, Orbit, Neck w/ Contrast Gadolinium PA Medical Necessity Review
Radiology MRI 70543 MRI Face, Orbit, Neck w & w/o Contrast Gadolinium PA Medical Necessity Review
Radiology MRA 70544 MRA Head w/o Contrast Also known as MRV PA Medical Necessity Review
Radiology MRA 70545 MRA Head w/ Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review
Radiology MRA 70546 MRA Head w & w/o Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review
Radiology MRA 70547 MRA Neck w/o Contrast Also known as MRV PA Medical Necessity Review
Radiology MRA 70548 MRA Neck w/ Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review
Radiology MRA 70549 MRA Neck w & w/o Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review
Radiology MRI 70551 MRI Head w/o Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review
Radiology MRI 70552 MRI Head w/ Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review
Radiology MRI 70553 MRI Head w/ & w/o Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review
Page 1 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology MRI
70554
MRI, Brain, Functional MRI; Including Test Selection and Administration of Repetitive Body Part Movement and/or Visual Stimulation, Not Requiring Physician or Psychologist Administration
PA Medical Necessity Review
Radiology MRI70555
MRI, Brain, Functional MRI; Requiring Physician or Psychologist Administration of Entire Neurofunctional Testing
PA Medical Necessity Review
Radiology CT SCANS 71250 CT Thorax w/o Contrast Can be CT Chest or a Ultrafast‐CT/EBT/EBCTPA Medical Necessity Review
Radiology CT SCANS 71260 CT Thorax w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review
d l 71270 CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT d lRadiology CT SCANS 71270 CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review
Radiology CT SCANS 71275 Ct Angiography Chest PA Medical Necessity Review
Radiology MRI 71550 MRI Chest w/o Contrast Brachial Plexus PA Medical Necessity Review
Radiology MRI 71551 MRI Chest w/ Contrast PA Medical Necessity Review
Radiology MRI 71552 MRI Chest w/ & w/o Contrast Gadolinium PA Medical Necessity Review
Radiology MRA 71555 MRA Chest (Emc Myocardium) w/ or w/o Contrast
Gadolinium/ Also known as MRVPA Medical Necessity Review
Radiology CT SCANS 72126 CT C Spine w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 72127 CT C Spine w/o & w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 72128 CT T Spine w/o Contrast PA Medical Necessity Review
Radiology CT SCANS 72129 CT T Spine w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 72130 CT T Spine w/o & w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 72132 CT L Spine w/ Contrast Includes Sacrum PA Medical Necessity Review
Radiology CT SCANS 72133 CT L Spine w/o & w/ Contrast Includes Sacrum PA Medical Necessity Review
Radiology MRI 72141 MRI Cervical Spine w/o Contrast Vertebrae of the Neck PA Medical Necessity Review
Radiology MRI 72142 MRI Cervical Spine w/ Contrast Gadolinium PA Medical Necessity Review
Radiology MRI 72146 MRI Thoracic Spine w/o Contrast PA Medical Necessity Review
Radiology MRI 72147 MRI Thoracic Spine w/ Contrast Gadolinium PA Medical Necessity Review
Radiology MRI 72148 MRI Lumbar Spine w/o Contrast Includes Sacrum PA Medical Necessity Review
Page 2 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology MRI 72149 MRI Lumbar Spine w/ Contrast Gadolinium ‐ Includes Sacrum PA Medical Necessity Review
Radiology MRI 72156 MRI C Spine w/ & w/o Contrast Gadolinium PA Medical Necessity Review
Radiology MRI 72157 MRI T Spine w/ & w/o Contrast Gadolinium PA Medical Necessity Review
Radiology MRI 72158 MRI L Spine w/ & w/o Contrast Gadolinium ‐ Includes Sacrum PA Medical Necessity Review
Radiology MRA 72159 MRA Spinal Canal w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program
Radiology CT SCANS 72191 CT Angiography Pelvis Aortic Aneurysm Excluded from program
Radiology CT SCANS 72192 CT Pelvis w/o Contrast Below Belly Button/Coccyx PA Medical Necessity Review
Radiology CT SCANS 72193 CT Pelvis w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review
Radiology CT SCANS 72194 CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity ReviewRadiology CT SCANS 72194 CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review
Radiology MRI 72195 MRI Pelvis w/o Contrast Coccyx PA Medical Necessity Review
Radiology MRI 72196 MRI Pelvis w/ Contrast Gadolinium/coccyx PA Medical Necessity Review
Radiology MRI 72197 MRI Pelvis w & w/o Contrast Gadolinium/coccyx PA Medical Necessity Review
Radiology MRA 72198 MRA Pelvis w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program
Radiology CT SCANS 73200 CT Upper Extremity w/o Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review
Radiology CT SCANS 73201 CT Upper Extremity w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review
Radiology CT SCANS 73202 CT Upper Extremity w/o & w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review
Radiology CT SCANS 73206 CT Angiography Upper Extremity Hand/Arm/Shoulder/ Elbow/Wrist Excluded from program
Radiology MRI 73218 MRI Upper Extremity w/o Contrast Hand/Arm/Axilla PA Medical Necessity Review
Radiology MRI 73219 MRI Upper Extremity w/ Contrast Hand/Arm/Axilla‐Gadolinium PA Medical Necessity Review
Radiology MRI 73220 MRI Upper Extremity w & w/o Contrast Hand/Arm/Axilla‐Gadolinium PA Medical Necessity Review
Radiology MRI 73221 MRI Upper Extremity w/o Contrast Shoulder/Elbow/Wrist PA Medical Necessity Review
Radiology MRI 73222 MRI Upper Extremity w/ Contrast ArthrogramShoulder/Elbow/Wrist‐Gadolinium PA Medical Necessity Review
Radiology MRI 73223 MRI Upper Extremity Joint w & w/o Contrast Shoulder/Elbow/Wrist‐Gadolinium PA Medical Necessity Review
Radiology MRA 73225 MRA Upper Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program
Radiology CT SCANS 73700 CT Lower Extremity w/o Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review
Radiology CT SCANS 73701 CT Lower Extremity w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review
Page 3 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology CT SCANS 73702 CT Lower Extremity w/o & w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review
Radiology CT SCANS 73706 CT Angiography Lower Extremity Hip/Leg/Knee/Ankle/ Foot Excluded from program
Radiology MRI 73718 MRI Lower Extremity w/o Contrast Foot/Leg PA Medical Necessity Review
Radiology MRI 73719 MRI Lower Extremity w/ Contrast Foot/Leg‐Gadolinium PA Medical Necessity Review
Radiology MRI 73720 MRI Lower Extremity w/ & w/o Contrast Foot/Leg‐Gadolinium PA Medical Necessity Review
Radiology MRI 73721 MRI Lower Extremity w/o Contrast Hip/Knee/Ankle PA Medical Necessity Review
Radiology MRI 73722 MRI Lower Extremity w/ Contrast ArthrogramHip/Knee/Ankle‐Gadolinium PA Medical Necessity Review
Radiology MRI 73723 MRI Lower Extremity Joint w/ & w/o Contrast Hip/Knee/Ankle‐Gadolinium PA Medical Necessity Review
Radiology MRA 73725 MRA Lower Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program
Radiology CT SCANS 74150 CT Abdomen w/o Contrast Diaphragm to Belly Button PA Medical Necessity Review
Radiology CT SCANS 74160 CT Abdomen w/ Contrast Aneurysm/Diaphragm to Belly Button PA Medical Necessity Review
Radiology CT SCANS 74170 CT Abdomen w/o & w/ Contrast Diaphragm to Belly Button PA Medical Necessity Review
Radiology CT SCANS 74174Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Excluded from program
Radiology CT SCANS 74175 Ct Angiography Abdomen Diaphragm to Belly Button Excluded from program
Radiology MRI 74181 MRI Abdomen w/o Contrast MRCP‐MR Cholangiogram PA Medical Necessity Review
Radiology MRI 74182 MRI Abdomen w/ Contrast MRCP‐MR Cholangiogram Gadolinium PA Medical Necessity Review
Radiology MRI 74183 MRI Abdomen w/ & w/o Contrast MRCP‐MR Cholangiogram Gadolinium PA Medical Necessity Review
Radiology MRA 74185 MRA Abdomen w/ or w/o Contrast Also known as MRV Excluded from program
Radiology MRI 75557 Cardiac MRI For Morphology And Function Without Contrast Material Excluded from program
Radiology MRI75559
Cardiac MRI For Morphology And Function Without Contrast Material; With Stress Imaging Excluded from program
Radiology MRI75561
Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences
Excluded from program
Page 4 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology MRI
75563Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences; With Stress Imaging
Excluded from program
Radiology CT SCANS 76380 CT Limited or Localized Follow‐Up Study Excluded from program
Radiology MRI 76390 MRI Spectroscopy MRS Excluded from program
Radiology CT SCANS 76497 Unlisted Computed Tomography Procedure Excluded from program
Radiology MRI 76498 Unlisted MRI Procedure Redirect to valid code
Radiology MRI 76499 Unlisted Radiologic Procedure Excluded from program
Radiology ULTRASOUND U/S OB Pelvis, Pregnant Uterus, First Trimester gy76801
/ , g ,<14 Weeks Single Or First Gestation Excluded from program
Radiology ULTRASOUND76802
U/S OB Pelvis, Pregnant Uterus, First Trimester <14 Weeks Each Additional Gestation
Multiple Gestation onlyExcluded from program
Radiology ULTRASOUND 76805 U/S OB Pelvis, Pregnant Uterus, B‐Scan (Allowed Once Per Gestation)
Level 1 Excluded from program
Radiology ULTRASOUND
76810U/S OB Pelvis Complete, Multiple Gestation after 1st Trimester (Allowed Once For Each Additional Fetus per Gestation; Must Be Billed With 76805)
Multiple Gestation only
Excluded from program
Radiology ULTRASOUND
76811
US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Single or First Gestation (Allowed Once Per Gestation; Second Study Allowed If Performed By A Different Physician)
Level 2
Excluded from program
Cardiology CARDIAC IMPLANTABLES 33206Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33207Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Ventricular
PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33208Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial And Ventricular
PA Medical Necessity Review
Page 5 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CARDIAC IMPLANTABLES 33212Insertion or Replacement of Permanent Pacemaker Pulse Generator Only; Single Chamber, Atrial or Ventricular
PA Medical Necessity Review
Radiology ULTRASOUND
76812
US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Each Additional Gestation (Allowed Once For Each Additional Fetus Per Gestation; Must Be Billed With 76811; Second Study Allowed If Performed By A Different Physician)
Multiple Gestation only
Excluded from program
Radiology ULTRASOUND Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or
76813
y ,transvaginal approach; single or first gestation. (Allowed once per gestation) Excluded from program
Radiology ULTRASOUND
76814
Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) (Allowed once for each additional fetus per gestation)
Excluded from program
Radiology ULTRASOUND
76815
U/S Pregnant Uterus, Real Time w/ Image Documentation, Limited (E.G. Fetal Heart Beat, Placental Location, Fetal Position and/or Qualitative Amniotic Fluid Volume), 1 or More Fetuses
One CPT code per DOS regardless the # of fetuses
Excluded from program
Radiology ULTRASOUND 76816 U/S OB Pelvis Follow Up or Repeat One exam per fetus Excluded from program
Radiology ULTRASOUND 76817 US Pregnant Uterus Transvaginal One CPT code per DOS regardless the # of fetuses Excluded from program
Radiology ULTRASOUND 76818 Fetal Biophysical Profile One exam per fetus Excluded from program
Page 6 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology ULTRASOUND 76819 Fetal Biophysical Profile w/o Stress Non Stress One exam per fetusExcluded from program
Radiology ULTRASOUND 76820 Doppler Velocimetry, Fetal; Umbilical Artery One exam per fetus Excluded from program
Radiology ULTRASOUND 76821 Doppler Velocimetry, Fetal; Middle Cerebral Artery
One exam per fetusExcluded from program
Radiology ULTRASOUND 76825 U/S OB Echocardiography, Fetal, Cardiovascular System
Fetal EchoOne exam per fetus Excluded from program
Radiology ULTRASOUND 76826 Follow Up or Repeat Study One exam per fetus Excluded from program
Radiology ULTRASOUND 76827 Doppler Echocardiography Fetal Complete One exam per fetus Excluded from program
Radiology ULTRASOUND 76828 Follow Up or Repeat Study One exam per fetus Excluded from program
R di l ULTRASOUND U/S G i i l E d iRadiology ULTRASOUND 76975 U/S Gastrointestinal, Endoscopic Excluded from program
Radiology CT SCANS 77011 CT Guidance Sterotactic Localization Excluded from program
Radiology CT SCANS 77012 CT Guidance Needle BX‐RAD S & I Excluded from program
Radiology CT SCANS 77013 CT Guidance for and Monitoring of Tissue Ablation Excluded from program
Radiology CT SCANS 77014 CT Guidance for Placement of Radiation Therapy Fields Excluded from program
Radiology MRI 77021 MRI Guidance for Needle Placement Excluded from program
Radiology MRI 77022 MRI Guidance for and Monitoring of Tissue Ablation Excluded from program
Radiology MRI 77058 MRI Breast w/ and/or w/o Contrast; UnilateralUnilateral‐One‐Gadolinium PA Medical Necessity Review
Radiology MRI 77059 MRI Breast Bilateral Both PA Medical Necessity Review
Radiology CT SCANS 77078 CT Bone Density Study, Axial Skeleton Excluded from program
Radiology CT SCANS 77079 CT Bone Density Study, Appendicular SkeletonExcluded from program
Radiology MRI 77084 MRI Bone Marrow Blood Supply Excluded from program
Radiology NUCLEAR MED 78000 Thyroid uptake; single determination Redirect to valid code
Radiology NUCLEAR MED 78001 Thyroid uptake; multiple determinations Redirect to valid code
Radiology NUCLEAR MED78003
Thyroid uptake stimulation, suppression or discharge (not including initial uptake studies) Redirect to valid code
Page 7 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology NUCLEAR MED 78006 Thyroid imaging, with uptake; single determination Redirect to valid code
Radiology NUCLEAR MED 78007 Thyroid imaging, multiple determinations Redirect to valid code
Radiology NUCLEAR MED 78010 Thyroid imaging; only Redirect to valid code
Radiology NUCLEAR MED 78011 Thyroid imaging; with vascular flow Redirect to valid code
Radiology NUCLEAR MED
78012Thyroid Uptake, Single or Multiple Quantitative Measurements(s) (Including Stimulation, Suppression, or Discharge, When Performed) Excluded from program
Radiology NUCLEAR MED78013
Thyroid Imaging (Including Vascular Flow, When Performed) Excluded from program78013 Performed) p g
Radiology NUCLEAR MED
78014
Thyroid Imaging (Including Vascular Flow, When Performed); With Single or Multiple Uptake(s) Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed)
Excluded from program
Radiology NUCLEAR MED 78015 Thyroid Met Imaging Excluded from program
Radiology NUCLEAR MED 78016 Thyroid Met Imaging with Additional Studies Excluded from program
Radiology NUCLEAR MED 78018 Thyroid Scan Whole Body For CA thyroid (I‐ 31 scan) Excluded from program
Radiology NUCLEAR MED 78020 Thyroid Carcinoma Metastases Uptake Excluded from program
Radiology NUCLEAR MED
78070Parathyroid Planar Imaging (Including Subtraction, When Performed)
Excluded from program
Radiology NUCLEAR MED 78075 Adrenal Nuclear Imaging MIBG Excluded from program
Radiology NUCLEAR MED 78099 Unlisted Endocrine Procedure Excluded from program
Radiology NUCLEAR MED 78102 Bone Marrow Imaging, Limited Excluded from program
Radiology NUCLEAR MED 78103 Bone Marrow Imaging, Multiple Excluded from program
Radiology NUCLEAR MED 78104 Bone Marrow Imaging, Whole Body Excluded from program
Radiology NUCLEAR MED 78135 Differential Organ/Tissues Kinetic Excluded from program
Radiology NUCLEAR MED 78140 Labeled Red Cell Sequestration Excluded from program
Page 8 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology NUCLEAR MED 78185 Spleen Imaging w & w/o Vascular Flow Excluded from program
Radiology NUCLEAR MED 78190 Platelet Survival, Kinetics Excluded from program
Radiology NUCLEAR MED 78191 Platelet Survival Excluded from program
Radiology NUCLEAR MED 78195 Lymph System Imaging MIBG Excluded from program
Radiology NUCLEAR MED 78199 Unlisted Hematopoetic Procedure Excluded from program
Radiology NUCLEAR MED 78201 Liver Imaging Excluded from program
Radiology NUCLEAR MED 78202 Liver Imaging w/ Flow Excluded from program
Radiology NUCLEAR MED 78205 Liver Imaging Spect Excluded from program
Radiology NUCLEAR MED 78206 Liver Imaging Spect w/ Vascular Flow Excluded from programRadiology NUCLEAR MED 78206 Liver Imaging Spect w/ Vascular Flow Excluded from program
Radiology NUCLEAR MED 78215 Liver and Spleen Imaging Red Cell Tagging Excluded from program
Radiology NUCLEAR MED 78216 Liver and Spleen Imaging w/ Flow Excluded from program
Radiology NUCLEAR MED 78226 Hepatobiliary system imaging, including gallbladder when present; Excluded from program
Radiology NUCLEAR MED
78227
Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed
Excluded from program
Radiology NUCLEAR MED 78230 Salivary Gland Imaging Excluded from program
Radiology NUCLEAR MED 78231 Serial Salivary Gland Excluded from program
Radiology NUCLEAR MED 78232 Salivary Gland Function Test Excluded from program
Radiology NUCLEAR MED 78258 Esophagus Motility Study Excluded from program
Radiology NUCLEAR MED 78261 Gastric Mucosa Imaging Excluded from program
Radiology NUCLEAR MED 78262 Gastroesophagael Reflum Emam Excluded from program
Radiology NUCLEAR MED 78264 Gastric Emptying Study Excluded from program
Radiology NUCLEAR MED 78278 GI Bleeder Scan Excluded from program
Radiology NUCLEAR MED 78282 GI Protein Loss Exam Excluded from program
Radiology NUCLEAR MED 78290 Meckel's Diverticulum Imaging Excluded from program
Radiology NUCLEAR MED 78291 Leveen Shunt Patency Exam Excluded from program
Page 9 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology NUCLEAR MED 78299 Unlisted Gastroinestinal Procedure Excluded from program
Radiology NUCLEAR MED 78300 Bone or Joint Imaging Ltd One Bone Excluded from program
Radiology NUCLEAR MED 78305 Bone or Joint Imaging Multiple More than one Bone Excluded from program
Radiology NUCLEAR MED 78306 Bone Scan Whole Body Used Often with CA studies/All bones Excluded from program
Radiology NUCLEAR MED 78315 Bone and/or Joint Imaging; 3 Phase Study OsteomyelitisTechnesium 99 Excluded from program
Radiology NUCLEAR MED 78320 Bone Joint Imaging Tomo Test Spect Excluded from program
Radiology NUCLEAR MED 78399 Unlisted Musculoskeletal Procedure Excluded from program
Radiology NUCLEAR MED 78414 Non‐Imaging Heart Function Excluded from program
Radiology NUCLEAR MED 78428 Cardiac Shunt Imaging Excluded from program
Radiology NUCLEAR MED 78445 Radionuclide Venogram Non‐Cardiac Excluded from program
Radiology NUCLEAR MED 78456 Acute Venous Thrombosis Imaging Excluded from program
Radiology NUCLEAR MED 78457 Venous Thrombosis Imaging Unilateral Excluded from program
Radiology NUCLEAR MED 78458 Venous Thrombosis Imaging Bilateral Excluded from program
Radiology PET SCANS 78459 Myocardial Imaging, Positron Emission Tomography (PET) Metabolic Eval. PA Medical Necessity Review
Radiology NUCLEAR MED 78466 Myocardial Infarction Scan Excluded from program
Radiology NUCLEAR MED 78468 Heart Infarct Image Ef Excluded from program
Radiology NUCLEAR MED 78469 Heart Infarct Image Spect Excluded from program
Radiology NUCLEAR MED 78472 Gated Heart, Rest or Stress Excluded from program
Radiology NUCLEAR MED 78473 Cardiac Blood Pool Muga Scan Excluded from program
Radiology NUCLEAR MED 78481 Heart First Pass Single PA Medical Necessity Review
Radiology NUCLEAR MED 78483 Cardiac Blood Pool Imaging, Multi PA Medical Necessity Review
Radiology PET SCANS78491
Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Single Study At Rest Or Stress
PA Medical Necessity Review
Radiology PET SCANS78492
Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Multiple Studies At Rest Or Stress
PA Medical Necessity Review
Page 10 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology NUCLEAR MED 78494 Cardiac Blood Pool Imaging, Spect PA Medical Necessity Review
Radiology NUCLEAR MED 78496 Cardiac Blood Pool Imaging, Single at Rest PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33213 Insertion Of Pacemaker Pulse Generator Only; With Existing Dual Leads PA Medical Necessity Review
Radiology NUCLEAR MED 78499 Unlisted Cardiovascular Procedure Excluded from program
Cardiology CARDIAC IMPLANTABLES 33214
Upgrade Of Implanted Pacemaker System, Conversion Of Single Chamber System To Dual Chamber System (Includes Removal Of Previously Placed Pulse Generator, Testing Of Existing Lead, Insertion Of New Lead, Insertion Of New Generator)
PA Medical Necessity Review
)
Radiology NUCLEAR MED78579
Pulmonary ventilation imaging (eg, aerosol or gas) Excluded from program
Radiology NUCLEAR MED 78580 Pulmonary perfusion imaging (eg, particulate);Excluded from program
Radiology NUCLEAR MED 78582 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Excluded from program
Radiology NUCLEAR MED78597
Quantitative differential pulmonary perfusion, including imaging when performed Excluded from program
Radiology NUCLEAR MED78598
Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed
Excluded from program
Radiology NUCLEAR MED 78599 Unlisted Respiratory Procedure Excluded from program
Radiology NUCLEAR MED 78600 Brain Imaging Ltd Static Excluded from program
Radiology NUCLEAR MED 78601 Brain Ltd Imaging and Flow Excluded from program
Radiology NUCLEAR MED 78605 Brain Imaging Complete Excluded from program
Radiology NUCLEAR MED 78606 Brain Imaging Complete w/ Flow Excluded from programRadiology NUCLEAR MED 78607 Brain Imaging Spect SPECT Excluded from program
Radiology PET SCANS 78608 Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation PA Medical Necessity Review
Page 11 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology PET SCANS 78609 Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation PA Medical Necessity Review
Radiology NUCLEAR MED 78610 Brain Flow Imaging Only Excluded from program
Radiology NUCLEAR MED 78630 Cisternogram (Cerebrospinal Fluid Flow) Excluded from program
Radiology NUCLEAR MED 78635 Cerebrospinal Ventriculography Excluded from program
Radiology NUCLEAR MED 78645 CSF Shunt Evaluation Excluded from program
Radiology NUCLEAR MED 78647 Cerebrospinal Fluid Scan Spect Excluded from program
Radiology NUCLEAR MED 78650 CSF Leakage Detection and Localization Excluded from program
Radiology NUCLEAR MED 78660 Radiopharmaceutical Dacryocystorgraphy Excluded from program
Radiology NUCLEAR MED 78699 Unlisted Nuclear Medicine Procedure Excluded from program
Radiology NUCLEAR MED 78700 Kidney Imaging Morphology Excluded from program
Radiology NUCLEAR MED 78701 Kidney Imaging Morphology w/ Vascular FlowExcluded from program
Radiology NUCLEAR MED 78707 Kidney Imaging Morphology w/ Vascular Flow and Function Study
Renal ScanExcluded from program
Radiology NUCLEAR MED78708
Kidney Imaging Morphology w/ Vascular Flow and Function, Single w/ Pharm Intervention Excluded from program
Radiology NUCLEAR MED 78709 Kidney Imaging Morphology w/ Vascular Flow, Multi, w/o and w/ Pharm Intervention
Captorpril/Renal Scan/MAG 3Excluded from program
Radiology NUCLEAR MED 78710 Kidney Imaging, Spect Excluded from program
Radiology NUCLEAR MED 78725 Kidney Function Study, Non‐Image RadioisotropicExcluded from program
Radiology NUCLEAR MED 78730 Urinary Bladder Residual Study Excluded from program
Radiology NUCLEAR MED 78740 Ureteral Reflum Study VCUG/Cystogram Excluded from program
Radiology NUCLEAR MED 78761 Testicular Imaging w/ Vascular Flow Excluded from program
Radiology NUCLEAR MED 78799 Unlisted Genitourinary Procedure Excluded from program
Radiology NUCLEAR MED 78800 Radiopharm Localization of Tumor, Limited AreaExcluded from program
Radiology NUCLEAR MED 78801 Radiopharm Localization of Tumor, Multi Areas Gallium Scan/Mammo Scintogram/OctreoScan Excluded from program
Page 12 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology NUCLEAR MED 78802 Radiopharm Localization of Tumor, Whole Body Gallium Scan/Octreo ScanExcluded from program
Radiology NUCLEAR MED 78803 Radiopharm Localization of Tumor, Spect Gallium Scan/FUO Excluded from program
Radiology NUCLEAR MED
78804Radiopharmaceutical Localization of Tumor or Distribution of Radiopharmaceutical Agent(s); Whole Body, Requiring 2 or More Days Imaging Excluded from program
Radiology NUCLEAR MED 78805 Radiopharm Localization of Abscess, Limited Area Gallium Scan/Indium Scan/WBC Scan/MBIGExcluded from program
Radiology NUCLEAR MED 78806 Radiopharm Localization of Abscess, Whole Body Gallium Scan/Indium Scan/WBC Scan/MBIGExcluded from program
Radiology NUCLEAR MED Radiopharm Localization of Abscess Spect Galliium Scan/Indium Scan/WBC Scan/MBIGRadiology NUCLEAR MED 78807 Radiopharm Localization of Abscess, Spect Galliium Scan/Indium Scan/WBC Scan/MBIGExcluded from program
Radiology PET SCANS78811
Positron Emission Tomography (PET) Imaging; Limited Area (Eg, Chest, Head/Neck) PA Medical Necessity Review
Radiology PET SCANS 78812 Positron Emission Tomography (PET) Imaging; Skull Base To Mid‐Thigh PA Medical Necessity Review
Radiology PET SCANS 78813 Positron Emission Tomography (PET) Imaging; Whole Body PA Medical Necessity Review
Radiology PET SCANS
78814
Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Limited Area (Eg Chest, Head/Neck)
PET with CT
PA Medical Necessity Review
Radiology PET SCANS
78815
Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Skull Base to Mid‐Thigh
PET with CT
PA Medical Necessity Review
Radiology PET SCANS
78816
Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Whole Body
PET with CT
PA Medical Necessity Review
Radiology NUCLEAR MED 78999 Unlisted Misc. Procedeure Diagnostic Nuclear Med Excluded from program
Page 13 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology T‐CODES 0042T CT Perfusion BrainInvestigational
Radiology T‐CODES
0159T
Computer‐Aided Detection, Including Computer Algorithm Analysis of MRI Image Data For Lesion Detection/Characterization, Pharmacokinetic Analysis, with Further Physician Review for Interpretation, Breast MRI (List Separately In Addition To Code For Primary Procedure)
Not Covered
Radiology CT SCANS 70460 CT Head/Brain w/ Contrast PA Medical Necessity Review
Radiology CT SCANS 72125 CT C Spine w/o Contrast PA Medical Necessity Review72125 y
Radiology CT SCANS 72131 CT L Spine w/o Contrast PA Medical Necessity Review
Radiology CT SCANS 74176 Computed Tomography, Abdomen and Pelvis; without Contrast Material PA Medical Necessity Review
Radiology CT SCANS 74177 Computed Tomography, Abdomen and Pelvis; with Contrast Material(s) PA Medical Necessity Review
Radiology CT SCANS 74178
Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(s) And Further Sections In One Or Both Body Regions
PA Medical Necessity Review
RadiologyCT SCANS 74261
Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material
PA Medical Necessity Review
Radiology
CT SCANS 74262Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; With Contrast Material(s) Including Non‐Contrast Images, If Performed
PA Medical Necessity Review
RadiologyCT SCANS 74263 Computed Tomographic (CT) Colonography,
Screening, Including Image Postprocessing PA Medical Necessity Review
Radiology MRI75565
Cardiac MRI For Velocity Flow Mapping (List Separately In Addition To Code For Primary Procedure)
Excluded from program
RadiologyCT SCANS 75571 CT Heart Without Contrast Material, With
Quantitive Evaluation Of Coronary Calcium PA Medical Necessity Review
Page 14 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology CT SCANS 75572 Cardiac CT For Morphology PA Medical Necessity Review
Radiology CT SCANS 75573 Cardiac CT For Congenital HD PA Medical Necessity Review
Radiology CT SCANS 75574 CT Angio Coronary Artery PA Medical Necessity Review
Radiology CT SCANS 75635 CT Angiography Abdominal Aorta Aortic Aneurysm Excluded from program
Radiology 3DI 76376
3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Not Requiring Image Postprocessing On An Independent Workstation
Excluded from program
Radiology 3DI 76377
3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation
Excluded from program
Radiology NUCLEAR MED78071
Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect)
Excluded from program
Radiology NUCLEAR MED
78072
Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect), And Concurrently Acquired Computed Tomography (CT) For Anatomical Localization
Excluded from program
Radiology NUCLEAR MED 78451 MPI, Spect, Single Rest or Stress PA Medical Necessity Review
Radiology NUCLEAR MED 78452 MPI, Spect, Multiple Rest or Stress PA Medical Necessity Review
Radiology NUCLEAR MED 78453 MPI, Planar, Single Rest or Stress PA Medical Necessity Review
Radiology NUCLEAR MED 78454 MPI, Planar, Multiple Rest or Stress Excluded from program
Radiology C‐CODES C8900 MRA with Contrast, Abdomen Excluded from program
Page 15 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology C‐CODES C8901 MRA without Contrast, Abdomen Excluded from program
Radiology C‐CODES C8902 MRA with and without Contrast, Abdomen Excluded from program
Radiology C‐CODES C8903 MRI with Contrast, Breast; Unilateral Excluded from program
Radiology C‐CODES C8904 MRI without Contrast, Breast; Unilateral Excluded from program
Radiology C‐CODES C8905 MRI with and without Contrast, Breast; Unilateral Excluded from program
Radiology C‐CODES C8906 MRI with Contrast, Breast; Bilateral Excluded from program
Radiology C‐CODES C8907 MRI without Contrast, Breast; Bilateral Excluded from program
Radiology C‐CODES C8908 MRI with and without Contrast, Breast; Bilateral Excluded from program
Radiology C‐CODES C8909 MRA with Contrast, Chest (Excluding Myocardium) Excluded from program
Radiology C‐CODES C8910 MRA without Contrast, Chest (Excluding Myocardium) Excluded from program
Radiology C‐CODES C8911 MRA with and Without Contrast, Chest (Excluding Myocardium) Excluded from program
Radiology C‐CODES C8912 MRA with Contrast, Lower Extremity Excluded from program
Radiology C‐CODES C8913 MRA without Contrast, Lower Extremity Excluded from program
Radiology C‐CODES C8914 MRA with and Without Contrast, Lower Extremity Excluded from program
Radiology C‐CODES C8918 MRA with Contrast, Pelvis Excluded from program
Radiology C‐CODES C8919 MRA without Contrast, Pelvis Excluded from program
Radiology C‐CODES C8920 MRA with and without Contrast, Pelvis Excluded from program
Page 16 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiology C‐CODES
C8921
Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; Complete
Excluded from program
Radiology C‐CODESC8922
Transthoracic Echocardiography w/Contrast for Congenital Cardiac Anomalies; F/U or Limited Study
Excluded from program
Radiology C‐CODESC8923
Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w or w/o M‐Mode Recording; Complete
Excluded from program
Radiology C‐CODES
C8924Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w or w/o M‐Mode Recording; F/U Or Limited Study Excluded from program
Radiology C‐CODES
C8928
Transthoracic Echocardiography with Contrast, Real Time w/Image Documentation (2D), w/ or w/o M‐Mode Recording, During Rest And Cardiovascular Stress Test, w/Interpretation and Report (Crosswalked To Either 93350 Or 93351)
Excluded from program
RADIOLOGY C‐CODES
C8929
Transthoracic Echocardiography with Contrast, or without Contrast Followed By with Contrast, Real‐Time with Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, with Spectral Doppler Echocardiography, and with Color Flow Doppler Echocardiography
Excluded from program
Page 17 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
RADIOLOGY C‐CODES
C8930
Transthoracic Echocardiography, with Contrast, or without Contrast Followed By with Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, with Interpretation and Report; Including Performance of Continuous Electrocardiographic Monitoring, with Physician Supervision
Excluded from program
RADIOLOGY C‐CODES C8931 Magnetic Resonance Angiography with Contrast, Spinal Canal and Contents Excluded from program
RADIOLOGY C‐CODES C8932 Magnetic Resonance Angiography without Contrast, Spinal Canal and Contents Excluded from program
RADIOLOGY C‐CODESC8933
Magnetic Resonance Angiography without Contrast Followed by with Contrast, Spinal Canal and Contents
Excluded from program
RADIOLOGY C‐CODES C8934 Magnetic Resonance Angiography with Contrast, Upper Extremity Excluded from program
RADIOLOGY C‐CODES C8935 Magnetic Resonance Angiography without Contrast, Upper Extremity Excluded from program
RADIOLOGY C‐CODESC8936
Magnetic Resonance Angiography without Contrast Followed by with Contrast, Upper Extremity
Excluded from program
Radiology G‐CODESG0219
Pet Imaging Whole Body; Melanoma for Non‐Covered Indications Investigational
Radiology G‐CODES G0235 Pet Imaging, Any Site, Not Otherwise SpecifiedRedirect to valid code
Radiology G‐CODES
G0252Pet Imaging, Full and Partial‐Ring Pet Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer Redirect to valid code
Cardiology CARDIAC IMPLANTABLES 33221 Insertion Of Pacemaker Pulse Generator Only; With Existing Multiple Leads PA Medical Necessity Review
Page 18 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CARDIAC IMPLANTABLES 33224
Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, With Attachment To Previously Placed Pacemaker Or Implantable Defibrillator Pulse Generator (Including Revision Of Pocket, Removal, Insertion, And/Or Replacement Of Existing Generator)
PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33225
Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, At Time Of Insertion Of Implantable Defibrillator Or Pacemaker Pulse Generator (Eg, For Upgrade To Dual Chamber System) (List Separately In
PA Medical Necessity ReviewDual Chamber System) (List Separately In Addition To Code For Primary Procedure)
Cardiology CARDIAC IMPLANTABLES 33227Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System
PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33228Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System
PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33229Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Multiple Lead System
PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33230 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Dual Leads PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33231 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Multiple Leads PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33240 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Single Lead PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33249Insertion Or Replacement Of Permanent Implantable Defibrillator System With Transvenous Lead(s), Single Or Dual Chamber PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33262Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Single Lead System PA Medical Necessity Review
Page 19 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CARDIAC IMPLANTABLES 33263Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Dual Lead System PA Medical Necessity Review
Cardiology CARDIAC IMPLANTABLES 33264Removal of Implantable Defibrillator Pulse Generator with Replacement of Pacing Cardioverter‐Defibrillator Pulse Generator; Multiple Lead System
PA Medical Necessity Review
Insertion Or Replacement Of Permanent Subcutaneous Implantable Defibrillator System, with Subcutaneous Electrode, Including Defibrillation Threshold Evaluation, Indication of
Cardiology CARDIAC IMPLANTABLES 33270 Arrythmia,Evaluation Of Sensing For Arrythmia Termination, and Programming Or Reprogramming Of Sensing Or Therapeutic Parameters When Performed
PA Medical Necessity Review
Cardiology MRI 75557Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material
Excluded from program
Cardiology MRI 75559Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material; With Stress Imaging
Excluded from program
Cardiology MRI 75561Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences
Excluded from program
Cardiology MRI 75563
Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences; With Stress Imaging
Excluded from program
Cardiology MRI 75565Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)
Excluded from program
Page 20 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CT SCANS 75571Computed Tomography, Heart, Without Contrast Material, With Quantitative Evaluation Of Coronary Calcium
Excluded from program(Managed Under Radiology)
Cardiology CT SCANS 75572
Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology (Including 3D Image Post processing, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed)
Excluded from program(Managed Under Radiology)
Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology In The Setting Of Congenital Heart
Cardiology CT SCANS 75573
p gy g gDisease (Including 3D Image Post processing, Assessment Of LV Cardiac Function, RV Structure And Function And Evaluation Of Venous Structures, If Performed)
Excluded from program(Managed Under Radiology)
Radiology CT SCANS S8032
Low‐Dose Computed Tomography for Lung Cancer Screening
PA Medical Necessity Review
Cardiology CT SCANS 75574
Computed Tomographic Angiography, Heart, Coronary Arteries And Bypass Grafts (When Present), With Contrast Material, Including 3D Image Post processing (Including Evaluation Of Cardiac Structure And Morphology, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed)
Excluded from program(Managed Under Radiology)
Radiology S‐CODES S8037 Magnetic Resonance Cholangiopancreatography (MRCP) Redirect to valid code
Radiology S‐CODES S8042 Magnetic Resonance Imaging (MRI), Low‐Field Redirect to valid code
Page 21 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology NUCLEAR STRESS 78451
Myocardial Perfusion Imaging, Tomographic (SPECT) Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic)
Excluded from program(Managed Under Radiology)
Radiology S‐CODES
S8080
Scintimammography (Radioimmunoscintigraphy of the Breast), Unilateral, Including Supply of Radiopharmaceutical
Excluded from programS8080 p g
Cardiology NUCLEAR STRESS 78452
Myocardial Perfusion Imaging, Tomographic (SPECT) (Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest and/or Stress (Exercise Or Pharmacologic) and/or Redistribution and/or Rest Reinjection
Excluded from program(Managed Under Radiology)
Radiology S‐CODES
S8085
Fluorine‐18 Fluorodeomyglucose (F‐18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non‐Dedicated PET Scan)
Investigational
Page 22 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology NUCLEAR STRESS 78453
Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic)
Excluded from program(Managed Under Radiology)
Radiology S‐CODES
S8092
Electron Beam Computed Tomography (Also Known as Ultrafast CT, Cinet)
Excluded from program
Cardiology NUCLEAR STRESS 78454
Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest and/or Stress (Exercise Or Pharmacologic) and/or Redistribution and/or Rest Reinjection
Excluded from program(Managed Under Radiology)
Cardiology PET 78459 PET Myocardial Imaging; Positron Emission Tomography (PET) Metabolic Evaluation
Excluded from program(Managed Under Radiology)
Cardiology NUCLEAR MED 78472 Gated Cardiac Radionuclide Angiography Excluded from program
Cardiology NUCLEAR MED 78473 Gated Multiple Cardiac Radionuclide AngiographyExcluded from program
Cardiology NUCLEAR MED 78481 Planar First Pass Cardiac Radionuclide Angiography
Excluded from program(Managed Under Radiology)
Cardiology NUCLEAR MED 78483 Planar First Pass Multiple Cardiac Radionuclide Angiography
Excluded from program(Managed Under Radiology)
Cardiology PET 78491Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Single Study, Rest or Stress Excluded from program
(Managed Under Radiology)
Cardiology PET 78492Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Multiple Studies, Rest and/or Stress
Excluded from program(Managed Under Radiology)
Page 23 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology NUCLEAR MED 78494 SPECT Equilbrium Cardiac Radionuclide Angiography
Excluded from program(Managed Under Radiology)
Cardiology NUCLEAR MED 78496 SPECT EquilbriumMultiple Radionuclide Angiography
Excluded from program(Managed Under Radiology)
Cardiology ECHOCARDIOGRAPHY 93303 Transthoracic Echocardiography For Congenital Cardiac Anomalies; Complete Excluded from program
Cardiology ECHOCARDIOGRAPHY 93304Transthoracic Echocardiography For Congenital Cardiac Anomalies; Follow‐Up Or Limited Study Excluded from program
C di l ECHOCARDIOGRAPHY 93306
Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, With
E l d d fCardiology ECHOCARDIOGRAPHY 93306g, , p ,
Spectral Doppler Echocardiography, And With Color Flow Doppler Echocardiography
Excluded from program
Cardiology ECHOCARDIOGRAPHY 93307Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐Mode Recording; Complete
Excluded from program
Cardiology ECHOCARDIOGRAPHY 93308Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐Mode Recording; Follow‐Up Or Limited Study Excluded from program
Cardiology ECHOCARDIOGRAPHY 93320Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Complete
Excluded from program
Cardiology ECHOCARDIOGRAPHY 93321Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Follow‐Up Or Limited Study
Excluded from program
Cardiology ECHOCARDIOGRAPHY 93325 Doppler Echocardiography Color Flow Velocity Mapping Excluded from program
Cardiology ECHO STRESS 93350
Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), With Or Without M‐Mode Recording, During Rest And Cardiovascular Stress Test, With Interpretation And Report
Excluded from program
Page 24 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology ECHO STRESS 93351
Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, With Interpretation And Report; Including Performance Of Continuous Electrocardiographic Monitoring, With Supervision By A Physician Or Other Qualified Health Care Professional.
Excluded from program
Use of echocardiographic contrast agent during
Cardiology ECHO STRESS 93352Use of echocardiographic contrast agent duringstress echocardiography (List separately in addition to code for primary procedure) Excluded from program
Cardiology CARDIAC CATH 93452Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed
Excluded from program
Cardiology CARDIAC CATH 93453
Combined Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed
Excluded from program
Cardiology CARDIAC CATH 93454
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation
Excluded from program
Cardiology CARDIAC CATH 93455
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary Free Arterial Venous Grafts) Including
Excluded from program
Page 25 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CARDIAC CATH 93456
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right Heart Catheterization
Excluded from program
Cardiology CARDIAC CATH 93457
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary, Free Arterial, Venous Grafts)
Excluded from program
Including Intraprocedural Injection(s) For Bypass
Cardiology CARDIAC CATH 93458
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed
Excluded from program
Cardiology CARDIAC CATH 93459
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass G ft( ) (I t l M F A t i l
Excluded from program
Cardiology CARDIAC CATH 93460
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including
Excluded from program
Page 26 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology CARDIAC CATH 93461
Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass Graft(s) (Internal
Excluded from program
Radiation Therapy CPT 0182T High Dose Rate Electronic Brachytherapy, Per Fraction PA Medical Necessity Review
Radiation Therapy CPT 0190T Placement Of Intraocular Radiation Source Applicator PA Medical Necessity Review
Radiology/Therapeutic ‐ General ClassificationRadiation Therapy REV Code 0330 Radiology/Therapeutic ‐ General Classification
PA Medical Necessity Review
Radiation Therapy REV Code 0333 Radiology/Therapeutic ‐ Radiation Therapy PA Medical Necessity Review
Radiation Therapy REV Code 0339 Radiology/Therapeutic ‐ Other PA Medical Necessity Review
Radiation Therapy REV Code 0344 Therapeutic Radiopharmaceuticals PA Medical Necessity Review
Radiation Therapy REV Code 0973 Professional Fees ‐ Radiology/Therapeutic PA Medical Necessity Review
Radiation Therapy CPT 19296
Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy On Date Separate From Partial Mastectomy
PA Medical Necessity Review
Radiation Therapy CPT 19297
Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy, Concurrent With Partial Mastectomy)
PA Medical Necessity Review
Radiation Therapy CPT 19298Placement Of Radiation Therapy After loading Brachytherapy Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy
PA Medical Necessity Review
Radiation Therapy CPT 31643Bronchoscopy (Rigid Or Flexible), With Placement Of Catheter For Intracavitary Radioelement Application
PA Medical Necessity Review
Page 27 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 32553Placement Of Interstitial Device For Radiation Therapy Guidance, Percutaneous, Intra‐Thoracic, Single Or Multiple
PA Medical Necessity Review
Radiation Therapy CPT 41019 Placement Of Needles, Catheters, And Other Devices Into The Head and/or Neck Region PA Medical Necessity Review
Radiation Therapy CPT 43241
Upper Gastrointestinal Endoscopy Including Esophagus, Stomach And Either The Duodenum and/or Jejunum As Appropriate; W/ Transendoscopic Intraluminal Tube Or Catheter Placement
PA Medical Necessity Review
Placement Of Interstitial Device(s) For Radiation Therapy Guidance, Open, Intra‐Abdominal, Intra‐
Radiation Therapy CPT 49411py , p , ,
Pelvic and/or Retroperitoneum, Including Image Guidance, Single Or Multiple
PA Medical Necessity Review
Radiation Therapy CPT 49412
Placement Of Interstitial Device(s) For Radiation Therapy Guidance (Eg, Fiducial Markers, Dosimeter), Open, Intra‐Abdominal, Intrapelvic, and/or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To Code For Primary Procedure)
PA Medical Necessity Review
Radiation Therapy CPT 55875Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application, With Or Out Cytosocopy
PA Medical Necessity Review
Radiation Therapy CPT 55876 Fiducial Marker Placement In The Prostate PA Medical Necessity Review
Radiation Therapy CPT 55920
Placement Of Needles, Catheters, Or Other Device(s) Into The Head and/or Neck Region (Percutaneous, Transoral, Or Transnasal) For Subsequent Interstitial Radioelement Application
PA Medical Necessity Review
Radiation Therapy CPT 57155 Insertion Of Uterine Tandem and/or Vaginal Ovoids For Clinical Brachytherapy PA Medical Necessity Review
Page 28 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 57156Insertion Of A Vaginal Radiation After Loading Apparatus For Clinical Brachytherapy PA Medical Necessity Review
Radiation Therapy CPT 58346 Insertion Of Heyman Capsulesfor Clinical Brachytherapy PA Medical Necessity Review
Radiation Therapy CPT 76873 US Transrectal Prostate Volume Study For Brachytherapy PA Medical Necessity Review
Radiation Therapy CPT 76965 Ultrasound Guidance For Interstitial Radioelement Application PA Medical Necessity Review
Radiation Therapy CPT 77011 Computed Tomography Guidance For Stereotactic Localization PA Medical Necessity Review
R di ti Th CPT 77014 CT Guidance For Placement Of Radiation Therapy PA M di l N it R iRadiation Therapy CPT 77014 py
Fields PA Medical Necessity Review
Radiation Therapy CPT 77261 Therapeutic Radiology Treatment Planning; Simple PA Medical Necessity Review
Radiation Therapy CPT 77262 Therapeutic Radiology Treatment Planning; Intermediate PA Medical Necessity Review
Radiation Therapy CPT 77263 Therapeutic Radiology Treatment Planning; Complex PA Medical Necessity Review
Radiation Therapy CPT 77280 Therapeutic Radiology Simulation; Simple PA Medical Necessity Review
Radiation Therapy CPT 77285 Therapeutic Radiology Simulation; IntermediatePA Medical Necessity Review
Radiation Therapy CPT 77290 Therapeutic Radiology Simulation; Complex PA Medical Necessity Review
Radiation Therapy CPT 77293Respiratory Motion Management Simulation (List Separately In Addition To Code For Primary Procedure)
PA Medical Necessity Review
Radiation Therapy CPT 77295 3‐Dimensional Radiotherapy Plan, Including Dose‐Volume Histograms PA Medical Necessity Review
Radiation Therapy CPT 77299 Unlisted Procedure; Therapeutic Radiology Treatment Planning PA Medical Necessity Review
Radiation Therapy CPT 77300 Basic Radiation Dosimetry PA Medical Necessity Review
Radiation Therapy CPT 77301 IMRT Planning PA Medical Necessity Review
Radiation Therapy CPT 77306Teletherapy Isodose Plan; Simple (1 Or 2 Unmodified Ports Directed To A Single Area Of Interest), Includes Basic Dosimetry Calculation(s) PA Medical Necessity Review
Page 29 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 77307
Teletherapy Isodose Plan; Complex (Multiple Treatment Areas, Tangential Ports, The Use Of Wedges, Blocking, Rotational Beam, Or Special Beam Considerations), Includes Basic Dosimetry Calculation(s)
PA Medical Necessity Review
Radiation Therapy CPT 77316
Brachytherapy Isodose Plan; Simple (Calculation(s) Made From 1 To 4 Sources, Or Remote Afterloading Brachytherapy, 1 Channel), Includes Basic Dosimetry Calculation(S)
PA Medical Necessity Review
Brachytherapy Isodose Plan; Intermediate (Calculation(s) Made From 5 To 10 Sources, Or
Radiation Therapy CPT 77317( ( ) ,Remote Afterloading Brachytherapy, 2‐12 Channels), Includes Basic Dosimetry Calculation(S)
PA Medical Necessity Review
Radiation Therapy CPT 77318
Brachytherapy Isodose Plan; Complex (Calculation(s) Made From Over 10 Sources, Or Remote Afterloading Brachytherapy, 12 Channels), Includes Basic Dosimetry Calculation(s)
PA Medical Necessity Review
Radiation Therapy CPT 77321 Special Teletherapy Port Plan, Particles, Hemibody, Total Body PA Medical Necessity Review
Radiation Therapy CPT 77331 Special Radiation Dosimetry PA Medical Necessity Review
Radiation Therapy CPT 77332 Treatment Devices; Simple PA Medical Necessity Review
Radiation Therapy CPT 77333 Treatment Devices; Intermediate PA Medical Necessity Review
Radiation Therapy CPT 77334 Treatment Devices; Complex PA Medical Necessity Review
Radiation Therapy CPT 77336 Continuing Medical Physics Consultation PA Medical Necessity Review
Radiation Therapy CPT 77338Multi‐Leaf Collimator (MLC) Device(s) For IMRT, Design And Construction Per IMRT Plan PA Medical Necessity Review
Radiation Therapy CPT 77370 Special Medical Physics Consultation PA Medical Necessity Review
Radiation Therapy CPT 77371Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Multi‐Source Cobalt 60 Based PA Medical Necessity Review
Page 30 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 77372Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Linac Based
PA Medical Necessity Review
Radiation Therapy CPT 77373Stereotactic Body Radiation Therapy Delivery Per Fraction 1 Or More Lesions; Including Image Guidance Not To Exceed 5 Fractions
PA Medical Necessity Review
Radiation Therapy CPT 77385Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Simple
PA Medical Necessity Review
Radiation Therapy CPT 77386Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Complex
PA Medical Necessity Review; p
Radiation Therapy CPT 77387Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Delivery, Includes Intrafraction Tracking, When Performed PA Medical Necessity Review
Radiation Therapy CPT 77399 Unlisted Procedure, Medical Radiation PhysicsPA Medical Necessity Review
Radiation Therapy CPT 77401 Radiation Treatment Delivery, Superficial and/or Ortho Voltage, Per Day PA Medical Necessity Review
Radiation Therapy CPT 77402Radiation Treatment Delivery; Single Treatment Area, One Or Two Ports; And Two Or Fewer Simple Blocks; >1 MEV; Simple
PA Medical Necessity Review
Radiation Therapy CPT 77407Radiation Treatment Delivery; Two Separate Treatment Areas; Three Or More Ports On A Single Treatment Area; Or Three Or More Simple Blocks; >1 MEV; Intermediate
PA Medical Necessity Review
Radiation Therapy CPT 77412
Radiation Treatment Delivery; Three Or More Separate Treatment Areas; Custom Blocking; Tangential Ports; Wedges; Rotational Beam; Field‐In‐Field Or Other Tissue Compensation That Does Not Meet IMRT Guidelines; Or Electron Beam; >1 MEV; Complex
PA Medical Necessity Review
Radiation Therapy CPT 77417 Therapeutic Radiology Port Films PA Medical Necessity Review
Radiation Therapy CPT 77422 Neutron Beam TX, Simple PA Medical Necessity Review
Page 31 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 77423 Neutron Beam TX, Complex PA Medical Necessity Review
Radiation Therapy CPT 77424 Intraoperative Radiation Treatment Delivery, X‐Ray, Single Treatment Session PA Medical Necessity Review
Radiation Therapy CPT 77425 Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session PA Medical Necessity Review
Radiation Therapy CPT 77427 Radiation Treatment Management, Five Treatments PA Medical Necessity Review
Radiation Therapy CPT 77431Radiation Treatment Management, With Complete Course Of Therapy Consisting Of 1 ‐2 Fractions
PA Medical Necessity Review
Radiation Therapy CPT 77432Stereotactic Radiation Treatment Management Cerebral Lesion(s) Complete Course Of PA Medical Necessity ReviewRadiation Therapy CPT 77432 Cerebral Lesion(s) Complete Course Of Treatment Consisting Of 1 Session
PA Medical Necessity Review
Radiation Therapy CPT 77435Stereotactic Body Radiation Treatment Management Per Treatment Course; 1 Or More Lesions, Including Image Guidance Entire Course Not To Exceed 5 Fractions
PA Medical Necessity Review
Radiation Therapy CPT 77469 Intraoperative Radiation Treatment ManagementPA Medical Necessity Review
Radiation Therapy CPT 77470Special Treatment Procedure (Eg. Total Body Radiation, Hemibody Radiation Or Per Oral Endocavity)
PA Medical Necessity Review
Radiation Therapy CPT 77499 Unlisted Procedure, Therapeutic Radiology Treatment Management PA Medical Necessity Review
Radiation Therapy CPT 77520 Proton Treatment Delivery, Simple w/o Compensation PA Medical Necessity Review
Radiation Therapy CPT 77522 Proton Treatment Delivery, Simple w/ Compensation PA Medical Necessity Review
Radiation Therapy CPT 77523 Proton Treatment Delivery, Intermediate PA Medical Necessity Review
Radiation Therapy CPT 77525 Proton Treatment Delivery, Complex PA Medical Necessity Review
Radiation Therapy CPT 77600 Hyperthermia Treatment; Externally Generated, Deep PA Medical Necessity Review
Radiation Therapy CPT 77605 Hyperthermia Treatment; Externally Generated, Superficial PA Medical Necessity Review
Radiation Therapy CPT 77610 Hyperthermia Generated By Interstitial Probe(s); 5 Or Fewer Applicators PA Medical Necessity Review
Page 32 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy CPT 77615 Hyperthermia Generated By Interstitial Probe(s); 5 Or More Applicators PA Medical Necessity Review
Radiation Therapy CPT 77620 Hyperthermia Generated By Intracavitary Probe(s) PA Medical Necessity Review
Radiation Therapy CPT 77750 Infusion Or Instillation Of Radioelement Solution (Includes 3‐Month Follow‐Up Care) PA Medical Necessity Review
Radiation Therapy CPT 77761 Intracavitary Radiation Source Application; Simple PA Medical Necessity Review
Radiation Therapy CPT 77762 Intracavitary Radiation Source Application; Intermediate PA Medical Necessity Review
Radiation Therapy CPT 77763 Intracavitary Radiation Source Application; Complex PA Medical Necessity Reviewp
Radiation Therapy CPT 77776 Interstitial Radiation Source; Simple PA Medical Necessity Review
Radiation Therapy CPT 77777 Interstitial Radiation Source; Intermediate PA Medical Necessity Review
Radiation Therapy CPT 77778 Interstitial Radiation Source; Complex PA Medical Necessity Review
Radiation Therapy CPT 77785 Remote After loading High Dose Rate Radionuclide Brachytherapy; 1 Channel PA Medical Necessity Review
Radiation Therapy CPT 77786 Remote After loading High Dose Rate Radionuclide Brachytherapy; 2‐12 Channels PA Medical Necessity Review
Radiation Therapy CPT 77787Remote After loading High Dose Rate Radionuclide Brachytherapy; Over 12 Channels PA Medical Necessity Review
Radiation Therapy CPT 77789 Apply Surface Radiation PA Medical Necessity Review
Radiation Therapy CPT 77790 Radio Isotope Supervision, Handling, LoadingPA Medical Necessity Review
Radiation Therapy CPT 77799 Radium/Radioisotope Therapy PA Medical Necessity Review
Radiation Therapy HCPS A4648 Tissue Marker, Implantable, Any Type Each PA Medical Necessity Review
Radiation Therapy HCPS A4650 Implant Radiation Dosimeter, Each PA Medical Necessity Review
Radiation Therapy HCPS C1715 Brachytherapy Needle PA Medical Necessity Review
Radiation Therapy HCPS C1716 Brachytherapy Source, Non‐Stranded, Gold‐198, Per ... PA Medical Necessity Review
Radiation Therapy HCPS C1717 Brachytherapy Source, Non‐Stranded, Gold‐198 Per… PA Medical Necessity Review
Page 33 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy HCPS C1719 Brachytherapy Source, Non‐Stranded, Non‐High Dose ... PA Medical Necessity Review
Radiation Therapy HCPS C1728 Catheter, Brachytherapy Seed Administration PA Medical Necessity Review
Radiation Therapy HCPS C2616 Brachytherapy Source, Non‐Stranded, Yttrium ‐90, Per Source PA Medical Necessity Review
Radiation Therapy HCPS C2634 Brachytherapy Source, Non‐Stranded, High Activity,... PA Medical Necessity Review
Radiation Therapy HCPS C2635 Brachytherapy Source, Non‐Stranded, High Activity,... PA Medical Necessity Review
Radiation Therapy HCPS C2636 Brachytherapy Linear Source, Non‐Stranded, Paladiu... PA Medical Necessity Review
Radiation Therapy HCPS C2637 Brachytherapy Source, Non‐Stranded, Ytterbium‐169,... PA Medical Necessity Review
Radiation Therapy HCPS C2638 Brachytherapy Source, Stranded, Iodine‐125, Per So... PA Medical Necessity Review
Radiation Therapy HCPS C2639 Brachytherapy Source, Non‐Stranded, Iodine‐125, Per... PA Medical Necessity Review
Radiation Therapy HCPS C2640 Brachytherapy Source, Stranded, Palladium‐103, Per... PA Medical Necessity Review
Radiation Therapy HCPS C2641 Brachytherapy Source, Non‐Stranded, Palladium‐103,... PA Medical Necessity Review
Radiation Therapy HCPS C2642 Brachytherapy Source, Stranded, Cesium‐131, Per So... PA Medical Necessity Review
Radiation Therapy HCPS C2643 Brachytherapy Source, Non‐Stranded, Cesium‐131, Per... PA Medical Necessity Review
Radiation Therapy HCPS C2644 Brachytherapy Source, Cesium‐131 Chloride Solution, Per Millicurie PA Medical Necessity Review
Radiation Therapy HCPS C2698 Brachytherapy Source, Stranded, Not Otherwise Spec... PA Medical Necessity Review
Radiation Therapy HCPS C2699 Brachytherapy Source, Non‐Stranded, Not Otherwise PA Medical Necessity Review
Radiation Therapy HCPS C9725 Placement Ofÿendorectal Intracavitary Applicator For High Intensity Brachytherapy PA Medical Necessity Review
Page 34 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy HCPS C9726Placement And Removal (If Performed) Of Applicator Into Breast For Radiation Therapy (Packaged Into Payment For 77424 And 77425 As Of Jan 1, 2014)
PA Medical Necessity Review
Radiation Therapy HCPS C9728Placement Of Interstitial Device(S) For Radiation Therapy/Surgery Guidance( Eg, Fiducial Markers, Dosimeter), Other Than Prostrate (Any Approach), Single Or Multiple
PA Medical Necessity Review
Radiation Therapy HCPS G0339 Robotic Stereotactic Surgery 1 Session PA Medical Necessity Review
Radiation Therapy HCPS G0340 Robotic Stereotactic Radio Surgery 2 Through 5 Sessions PA Medical Necessity Review
Ultrasonic Guidance For Placement Of RadiationRadiation Therapy HCPS G6001
Ultrasonic Guidance For Placement Of Radiation Therapy Fields. MPFS Code In Place Of 76950 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6002Stereoscopic X‐Ray Guidance For Localization Of Target Volume For The Delivery Of Radiation Therapy. MPFS Code In Place Of 77421 For 2015 PA Medical Necessity Review
Radiation Therapy HCPS G6003
Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; Up To 5 MEV. MPFS Code In Place Of 77402 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6004
Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 6‐10 MEV. MPFS Code In Place Of 77403 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6005
Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 11‐19 MEV. MPFS Code In Place Of 77404 For 2015
PA Medical Necessity Review
Page 35 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy HCPS G6006
Radiation Treatment delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 20 MEV Or Greater. MPFS Code In Place Of 77406 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6007
Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; Up To 5 MEV. MPFS Code In Place Of 77407 For 2015
PA Medical Necessity Review
Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single
Radiation Therapy HCPS G6008, g
Treatment Area, Use Of Multiple Blocks; 6‐10 MEV. MPFS Code In Place Of 77408 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6009
Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; 11‐19 MEV. MPFS Code In Place Of 77409 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6010
Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; 20 MEV Or Greater. MPFS Code In Place Of 77411 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6011
Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; Up To 5 MEV. MPFS Code In Place Of 77412 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6012
Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 6‐10 MEV. MPFS Code In Place Of 77413 For 2015
PA Medical Necessity Review
Page 36 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy HCPS G6013
Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 11‐19 MEV. MPFS Code In Place Of 77414 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6014
Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 20, MEV Or Greater. MPFS Code In Place Of 77416 For 2015
PA Medical Necessity Review
Intensity Modulated Treatment Delivery, Single
Radiation Therapy HCPS G6015
Intensity Modulated Treatment elivery, SingleOr Multiple Fields/Arcs,Via Narrow Spatially And Temporally Modulated Beams, Binary, Dynamic MLC, Per Treatment Session. MPFS Code In Place Of 77418 For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6016
Compensator‐Based Beam Modulation Treatment Delivery Of Inverse Planned Treatment Using 3 Or More High Resolution (Milled Or Cast) Compensator, Convergent Beam Modulated Fields, Per Treatment Session. MPFS Code In Place Of 0073t For 2015
PA Medical Necessity Review
Radiation Therapy HCPS G6017
Intra‐Fraction Localization And Tracking Of Target Or Patient Motion During Delivery Of Radiation Therapy (Eg, 3D Positional Tracking, Gating, 3D Surface Tracking), Each Fraction Of Treatment. MPFS Code In Place Of 0197t For 2015
PA Medical Necessity Review
Radiation Therapy HCPS Q3001 Radioelements For Brachytherapy, Any Type, Each PA Medical Necessity Review
Radiation Therapy HCPS S2095Transcatheter Occlusion Or Embolization For Tumor Destruction, Percutaneous, Any Method, Using Yttrium‐90 Microspheres
PA Medical Necessity Review
Page 37 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Radiation Therapy HCPS S8030Scleral Application Of Tantalum Ring(s) For Localization Of Lesions For Proton Beam Therapy PA Medical Necessity Review
Sleep Therapies 94660Continuous Positive Airway Pressure Ventilation (CPAP), Initiation and Management PA Medical Necessity Review
Sleep Diagnostics 95782Polysomnography; Younger Than 6 Years, Sleep Staging With 4 Or More Additional Parameters Of Sleep, Attended By A Technologist PA Medical Necessity Review
Polysomnography; Younger Than 6 Years, Sleep Staging With 4 Or More Additional Parameters Of
Sleep Diagnostics 95783g g
Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist
PA Medical Necessity Review
Sleep Diagnostics 95800Sleep Study, Unattended, Simultaneous Recording; Heart Rate, Oxygen Saturation, Respiratory Analysis (E.G., By Airflow or Peripheral Arterial Tone), and Sleep Time
Excluded From Program
Sleep Diagnostics 95801Sleep Study, Unattended, Simultaneous Recording; Minimum of Heart Rate, Oxygen Saturation, and Respiratory Analysis (E.G., By Airflow or Peripheral Arterial Tone)
Excluded From Program
Sleep Diagnostics 95805 Multiple Sleep Latency Test Or Maintenance Of Wakefulness Test PA Medical Necessity Review
Sleep Diagnostics 95806
Sleep Study, Unattended, Simultaneous Recording Of, Heart Rate, Oxygen Saturation, Respiratory Airflow, And Respiratory Effort (E.G. Thoracoabdominal Movement)
PA Medical Necessity Review
Sleep Diagnostics 95807Sleep Study, Simultaneous Recording Of Ventilation, Respiratory Effort, ECG Or Heart Rate, And Oxygen Saturation, Attended By A Technologist
PA Medical Necessity Review
Page 38 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Sleep Diagnostics 95808Polysomnography; Any Age, Sleep Staging With 1‐3 Additional Parameters of Sleep, Attended By A Technologist
PA Medical Necessity Review
Sleep Diagnostics 95810Polysomnography; Age 6 Years or Older, Sleep Staging With 4 or More Additional Parameters of Sleep, Attended By A Technologist PA Medical Necessity Review
Sleep Diagnostics 95811
Polysomnography, Age 6 Years Or Older, Sleep Staging With 4 Or More Additional Parameters Of Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist – Diagnostic Split‐ PA Medical Necessity Reviewp g 95811Night Study (Psg And Cpap Titration); Sleep Testing; Age ≥ 6 Years
y
Sleep Management of Care A4604 Tubing With Integrated Heating Element For Use With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Diagnostics 95811
Polysomnography, Age 6 Years Or Older, Sleep Staging With 4 Or More Additional Parameters Of Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist – Attended Titration Of Positive Airway Pressure; Sleep Testing; Age ≥ 6 Years
PA Medical Necessity Review
Sleep Management of Care A7027 Combination Oral/Nasal Mask, Used With CPAP, Each PA Medical Necessity Review
Sleep Management of Care A7028 Oral Cushion For Combination Oral/Nasal Mask, Replacement Only PA Medical Necessity Review
Sleep Management of Care A7029 Nasal Pillows For Combination Oral/Nasal Mask, Replacement Only, Pair PA Medical Necessity Review
Sleep Management of Care A7030 Full Face Mask Used With Positive Airway Pressure Device, Each PA Medical Necessity Review
Sleep Management of Care A7031 Face Mask Interface, Replacement For Full Face Mask, Each PA Medical Necessity Review
Page 39 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Sleep Management of Care A7032 Cushion For Use On Nasal Mask Interface, Replace Only, Each PA Medical Necessity Review
Sleep Management of Care A7033 Pillow For Use On Nasal Cannula Type Interface, Replacement Only, Pair PA Medical Necessity Review
Sleep Management of Care A7034 Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7035 Headgear Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7036 Chinstrap Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7037 Tubing Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7038 Filter, Disposable, Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7039 Filter, Non‐Disposable, Used With Positive Airway Pressure Device PA Medical Necessity Review
Sleep Management of Care A7044 Oral Interface Used With Positive Airway Pressure Device, Each PA Medical Necessity Review
Sleep Management of Care A7045Exhalation Port With Or Without Swivel Used With Accessories For Positive Airway Devices, Replacement Only
PA Medical Necessity Review
Sleep Management of Care A7046Water Chamber For Humidifier, Used With Positive Airway Pressure Device, Replacement, Each
PA Medical Necessity Review
Sleep Therapies E0470
Respiratory Assist Device, Bi‐Level Pressure Capability without Backup Rate Feature, Used with Noninvasive Interface, E.G. Nasal or Facial Mask (Intermittent Assist Device with Continuous Positive Airway Pressure Device)
PA Medical Necessity Review
Sleep Therapies E0471
Respiratory Assist Device, Bi‐Level Pressure Capability, with Back‐Up Rate Feature, Used with Noninvasive Interface, E.G. Nasal or Facial Mask (Intermittent Assist Device with Continuous Positive Airway Pressure Device)
PA Medical Necessity Review
Sleep Therapies E0561 Humidifier, Non‐Heated, Used with Positive Airway Pressure Device PA Medical Necessity Review
Page 40 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Sleep Therapies E0562 Humidifier, Heated, Used with Positive Airway Pressure Device PA Medical Necessity Review
Sleep Therapies E0601 Positive Airway Pressure Therapy PA Medical Necessity Review
Sleep Diagnostics G0398
Home Sleep Study Test (HST) With Type II Portable Monitor, Unattended; Minimum Of 7 Channels: EEG, EOG, EMG, ECG/Heart Rate, Airflow, Respiratory Effort And Oxygen Saturation
PA Medical Necessity Review
Sleep Diagnostics G0399
Home Sleep Test (HST) With Type III Portable Monitor, Unattended; Minimum Of 4 Channels: 2 Respiratory Movement/Airflow, 1 ECG/Heart Rate And 1 Oxygen Saturation
PA Medical Necessity ReviewRate And 1 Oxygen Saturation
Sleep Diagnostics G0400Sleep Study, Unattended, Simultaneous Recording; Minimum Of Heart Rate, Oxygen Saturation, And Respiratory
PA Medical Necessity Review
Cardiology C‐CODES C8921 Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; Complete Excluded from program
Cardiology C‐CODES C8922Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; F/U Or Limited Study
Excluded from program
Cardiology C‐CODES C8923Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording; Complete
Excluded from program
Cardiology C‐CODES C8924Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording; F/U Or Limited Study Excluded from program
Cardiology C‐CODES C8928
Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording, During Rest And Cardiovascular Stress Test, w/Interpretation And Report
Excluded from program
Page 41 of 42
PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015
Cardiology C‐CODES C8929
Transthoracic Echocardiography With Contrast, Or Without Contrast Followed By With Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, With Spectral Doppler Echocardiography, And With Color Flow Doppler Echocardiography
Excluded from program
Transthoracic Echocardiography, With Contrast, Or Without Contrast Followed By With Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed,
Cardiology C‐CODES C8930
gDuring Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, With Interpretation And Report; Including Performance Of Continuous Electrocardiographic Monitoring, With Physician Supervision
Excluded from program
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