medicare advantage prior authorization list

Medicare Advantage Prior Authorization List
On behalf of Premera Blue Cross, Advantasure provides prior authorization services. Prior authorization is not a guarantee of payment. Benefits are based on eligibility at the time of service and are subject to
applicable contract terms.
Y0134_PriorAuthList_C FVNR 1019
We display one prior authorization list for all Premera Medicare Advantage plans.
• Providers: We recommend you review this list before you submit your requests.
• If indicated on this PA list, please submit PA requests directly to AIM: www.providerportal.com or Optum: www.providerexpress.com
• All DME costing >$1,000 requires prior authorization and is subject to clinical review for medical necessity, even if it is not listed on this Prior Authorization list.
• All Part B drugs are now grouped together at the end of the prior authorization list.
o HCPCS codes with a cross symbol (†) are for drugs that have prior authorization overlap with Part D formulary.
o HCPCS codes with a diamond symbol (◊) are for Part B drugs that require Step Therapy
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children
15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
15272 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)
15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 5/1/2018 Premera Blue Cross
Page 2 of 103 Premera Blue Cross Medicare Advantage Updated 02/11/2021
Code: Description: Effective
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 5/1/2018 Premera Blue Cross
15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 5/1/2018 Premera Blue Cross
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 5/1/2018 Premera Blue Cross
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 5/1/2018 Premera Blue Cross
1/1/2019 AIM Specialty Health AIM Provider Portal
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866-666-0776
19298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following partial mastectomy, includes image guidance
866-666-0776
19328 Removal of intact breast implant 5/1/2018 Premera Blue Cross
19330 Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel) 5/1/2018 Premera Blue Cross
19340 Insertion of breast implant on same day of mastectomy (i.e., immediate) 5/1/2018 Premera Blue Cross
19342 Insertion or replacement of breast implant on separate day from mastectomy 5/1/2018 Premera Blue Cross
19361 Breast reconstruction; with latissimus dorsi flap 5/1/2018 Premera Blue Cross
19364 Breast reconstruction; with free flap (e.g., fTRAM, DIEP, SIEA, GAP flap) 5/1/2018 Premera Blue Cross
19380 Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)
20555 Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)
866-666-0776
20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) 9/16/2020 Premera Blue Cross
20561 Needle insertion(s) without injection(s); 3 or more muscles 9/16/2020 Premera Blue Cross
20975 Electrical Stim Aid Bone Heal Invasive 5/1/2018 Premera Blue Cross
20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 5/1/2018 Premera Blue Cross
21082 Impress Custom Prep Palatal Augmentation 5/1/2018 Premera Blue Cross
21086 Impress Custom Prep Auricular Prosth 5/1/2018 Premera Blue Cross
21088 Impress Custom Prep Facial Prosth 5/1/2018 Premera Blue Cross
21121 Genioplasty Sliding Osteotomy Single Pie 5/1/2018 Premera Blue Cross
21145 Recon Midface Lefort I Single Graft 5/1/2018 Premera Blue Cross
21196 Recon Mand Ramus Sag Split W/Rigid Rix 5/1/2018 Premera Blue Cross
21210 Graft Bone Nasal Maxilla Malar Area 5/1/2018 Premera Blue Cross
21230 Graft Rib Cart to Face Chin Nose Ear 5/1/2018 Premera Blue Cross
21256 Recon Orbit W/ Osteotomies/Bone Grft 5/1/2018 Premera Blue Cross
21261 Rep Orbit Hypertelorism Combin Appr 5/1/2018 Premera Blue Cross
21263 Periorbital Osteotomy W/Graft Forehead A 5/1/2018 Premera Blue Cross
21268 Orbit Reposition Unilat W/Graft Intra/Ex 5/1/2018 Premera Blue Cross
21742 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), Wo Thoracoscopy
21743 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), w Thoracoscopy
22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical
22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic
22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar
22103 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure)
22116 Partial Excision of Vertebral Body for each additional Vertebral Segment 5/1/2018 Premera Blue Cross
22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging B229guidance; lumbosacral
22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cerv
22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb
22551 Arthrodesis, Anterior Interbody; Cervical Below C2 5/1/2018 Premera Blue Cross
22633 Arthrodesis, Combined Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspace & Segmt; Lumb
Contact for Review:
22634 Arthrodesis, Combind Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspce & Segmt ;Ea Addl
22841 Internal Spinal Fixation by Wiring of Spinous Processes 5/1/2018 Premera Blue Cross
22842 Instrumentat Post W Segment Wiring 5/1/2018 Premera Blue Cross
22843 Posterior Segmental Instrumentation, 7 To 12 Vertebral Segments 5/1/2018 Premera Blue Cross
22846 Anterior Instrumentation, 4 To 7 Vertebral Segments 5/1/2018 Premera Blue Cross
22847 Anterior Instrumentation, 8 or More Vertebral Segments 5/1/2018 Premera Blue Cross
22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect. (List separately in addition to code for primary procedure)
22856 Total Disc Arthroplasty, Anterior Approach, Including Discectomy with End Plate Preparation, Single Interspace, Cervical 5/1/2018 Premera Blue Cross
22864 Removal of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Cervical 5/1/2018 Premera Blue Cross
866-666-0776
27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft 5/1/2018 Premera Blue Cross
27446 Arthroplasty, knee, condyle and plateau, medial or lateral compartment 5/1/2018 Premera Blue Cross
27447 Arthroplasty, knee medical and lateral compartments with or without patella resurfacing(total knee arthroplasty) 5/1/2018 Premera Blue Cross
27702 Arthroplasty, Ankle; with Implant (Total) 5/1/2018 Premera Blue Cross
30410 Rhinoplasty, Prim; complete, Extern. Parts 5/1/2018 Premera Blue Cross
30420 Rhinoplasty Primary Maj Septal Rep 5/1/2018 Premera Blue Cross
30450 Rhinoplasty, 2ndary; major revision (nasal tip work and osteotomies) 5/1/2018 Premera Blue Cross
30460 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip and/or palate, incl columellar lengthening; tip only 5/1/2018 Premera Blue Cross
30462 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip and/or palate, incl columellar lengthening; tip, septum, osteotomies
30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) 7/6/2020 Premera Blue Cross
30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 7/6/2020 Premera Blue Cross
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation), transnasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g. balloon dilation) 5/1/2018 Premera Blue Cross
31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g. Balloon dilation) 5/1/2018 Premera Blue Cross
31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g. balloon dilation) 8/16/2018 Premera Blue Cross
866-666-0776
32850 Donor Pneumonectomy(ies) W Prep and Maintenance of Allograft (Cadaver) 5/1/2018 Premera Blue Cross
32852 Lung Transplant, Single, with Cardiopulmonary Bypass 5/1/2018 Premera Blue Cross
32853 Lung Transplant, Double (Sequential or En Bloc); Without Cardpulm Bypass 5/1/2018 Premera Blue Cross
32854 Lung Transplant, Double (Sequential or En Bloc); with CardPulm Bypass 5/1/2018 Premera Blue Cross
32855 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Unilateral 5/1/2018 Premera Blue Cross
32856 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Bilateral 5/1/2018 Premera Blue Cross
33206 Insertion of new or replacement of permanent Pacemaker with transvenous electrode(s) 6/4/2019 Premera Blue Cross
33207 Insertion of new or replacement of permanent Pacemaker with transvenous electrode(s) 6/4/2019 Premera Blue Cross
33208 Insertion of new or replacement of permanent Pacemaker with trans venous electrode(s) 6/4/2019 Premera Blue Cross
33210 Insertion or replacement of temporary lead/catheter – single chamber lead 6/4/2019 Premera Blue Cross
33212 Insertion of Pacemaker pulse generator only; with existing single lead 6/4/2019 Premera Blue Cross
33213 Insertion of Pacemaker pulse generator only; dual chamber 6/4/2019 Premera Blue Cross
33216 Insertion of a transvenous electrode, single lead 6/4/2019 Premera Blue Cross
33217 Insertion of transvenous electrodes, dual leads 6/4/2019 Premera Blue Cross
33221 Insertion of pacemaker pulse generator only; with existing multiple leads 6/4/2019 Premera Blue Cross
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)
Contact for Review:
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 addition to code for primary procedure)
33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads 6/4/2019 Premera Blue Cross
33231 Insertion of implantable defibrillator pulse generator only; with existing multiple leads 6/4/2019 Premera Blue Cross
33240 Insertion of implantable defibrillator pulse generator only; with existing single lead 6/4/2019 Premera Blue Cross
33935 Heart-Lung Transplant W Recipient Cardi/ 5/1/2018 Premera Blue Cross
33944 Backbench Standard Preparation Of Cadaver Donor Heart Allograft 5/1/2018 Premera Blue Cross
33945 Heart transplant, w/or without recipient cardiectomy 5/1/2018 Premera Blue Cross
34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrate; including four or more visceral artery endoprostheses (superior mesenteric, B388celiac and/or renal artery[s])
34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
34846 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption)
34848 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption)
36468 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk 5/1/2018 Premera Blue Cross
36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
36474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoa 7/6/2020 Premera Blue Cross
36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoa 7/6/2020 Premera Blue Cross
37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 5/1/2018 Premera Blue Cross
37718 Ligation, division, and stripping, short saphenous vein 5/1/2018 Premera Blue Cross
37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 5/1/2018 Premera Blue Cross
37735 Ligation & Strip Saphen+ulcer Unil 5/1/2018 Premera Blue Cross
37765 Stab Phlebectomy of Varicose Veins, One Extremity; 10-20 Stab Incisions 5/1/2018 Premera Blue Cross
37766 Stab Phlebectomy of Varicose Veins, One Extremity; More Than 20 Incisions 5/1/2018 Premera Blue Cross
37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 5/1/2018 Premera Blue Cross
37785 Ligation 2ndary Varicose Vein Unilateral 5/1/2018 Premera Blue Cross
38204 Management of Recipient Hematopoietic Progenitor Cell Donor Search and Cell Acquisition 5/1/2018 Premera Blue Cross
38212 Transplant Preparation of Hematopoietic Progenitor Cells; Red Blood Cell Removal 5/1/2018 Premera Blue Cross
38230 Harvest Bone Marrow For Transplant 5/1/2018 Premera Blue Cross
38240 Bone Marrow Trans plantation; Allogenic 5/1/2018 Premera Blue Cross
43644 Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux -En-Y Gastroenterostomy (Roux Limb <= 150 Cm)
43846 Gastric Bypass W/Roux-En-Y- Morbid Obesity 5/1/2018 Premera Blue Cross
Contact for Review:
43847 Gstrc Restricve Prcd w Gstrc Byps F Morbid Obesty; w/Sml Bowel Rcnstn 5/1/2018 Premera Blue Cross
43848 Revision of Gastrc Restrictive Prcd For Morbid Obesity (Separate Prcd) 5/1/2018 Premera Blue Cross
43882 Revision or Removal of Gastric Neurostimulator Electrodes, Antrum, Open 5/1/2018 Premera Blue Cross
44133 Donor Enterectomy, Open, w Allograft Prep & Maintenance; Living Donor 5/1/2018 Premera Blue Cross
47140 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Left Lateral Segment Only 5/1/2018 Premera Blue Cross
47141 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Left Lobectomy 5/1/2018 Premera Blue Cross
47142 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Right Lobectomy 5/1/2018 Premera Blue Cross
47143 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; Without Trisegment Or Lobe Split 5/1/2018 Premera Blue Cross
47144 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; W Trisegment Split Of Graft Into Two Partial Grafts
47145 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; With Lobe Split Of Graft Into Two Partial Grafts 5/1/2018 Premera Blue Cross
47146 Backbench Reconstruction Of Cadaver Or Living Donor Liver Gr aft Prior To Allotransplantation; Venous Anastomosis, Each
47147 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial Anastomosis, Each
47370 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Radiofrequency 5/1/2018 Premera Blue Cross
47371 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Cryosurgical 5/1/2018 Premera Blue Cross
47380 Ablation, Open, Of One Or More Liver Tumor(S); Radiofrequency 5/1/2018 Premera Blue Cross
47381 Ablation, Open, Of One Or More Liver Tumor(S); Cryosurgical 5/1/2018 Premera Blue Cross
47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation 5/1/2018 Premera Blue Cross
48552 Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis, Each 5/1/2018 Premera Blue Cross
48556 Removal of Transplanted Pancreatic Allograft 5/1/2018 Premera Blue Cross
50320 Donor Nephrectomy from Living Donor,Unil 5/1/2018 Premera Blue Cross
50323 Backbench Standard Preparation Of Cadaver Donor Renal Allograft 5/1/2018 Premera Blue Cross
50325 Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic) 5/1/2018 Premera Blue Cross
50327 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous Anastomosis, Each
50328 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial Anastomosis, Each
50329 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral Anastomosis, Each
53860 Transurethral Radiofrequency Micro- Remodeling Of The Female Bladder Neck And Proximal Urethra 5/1/2018 Premera Blue Cross
55873 Cryosurgical Ablation of the Prostate (Incl Ultrasonic Probe Placement) 5/1/2018 Premera Blue Cross
55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
866-666-0776
55920 Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
866-666-0776
57155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
57156 Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
58346 Insertion of Heyman capsules for clinical brachytherapy 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
61850 Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical 5/1/2018 Premera Blue Cross
61863 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First Array 5/1/2018 Premera Blue Cross
61864 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; ea addl Array
61867 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First Array 5/1/2018 Premera Blue Cross
61868 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; ea addl Array 5/1/2018 Premera Blue Cross
62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
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63003 Decompress Spine <2 Seg Thoracic 5/1/2018 Premera Blue Cross
63016 Decompress Spine >2 Seg Thoracic 5/1/2018 Premera Blue Cross
63020 Exc Iv Disk Cervical Unilat 5/1/2018 Premera Blue Cross
63030 Exc Iv Disk Lumbar Unilat 5/1/2018 Premera Blue Cross
63035 Exc Iv Disk Cervical/Lumb >1 Space 5/1/2018 Premera Blue Cross
63040 Laminotomy W Dec Nrv Rts;reex;cerv 5/1/2018 Premera Blue Cross
63042 Laminotomy W Dec Nrv Rts;reex;lumb 5/1/2018 Premera Blue Cross
63043 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Cerv Interspace 5/1/2018 Premera Blue Cross
63044 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Lumb Interspace 5/1/2018 Premera Blue Cross
63050 Laminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or More Vertebral Segments 5/1/2018 Premera Blue Cross
Contact for Review:
63051 Laminoplasty, Cerv, W Decompression Of Spinal Cord, 2 Or > Verteb Segments; W Reconstruction Of Posterior Bony Elements
63057 Decomp Spine Transpedic-Ea Add Seg 5/1/2018 Premera Blue Cross
63064 Decompress Spine Costoverteb 1 Seg 5/1/2018 Premera Blue Cross
63066 Decomp Spine Costoverteb-Ea Add Seg 5/1/2018 Premera Blue Cross
63076 Exc Iv Disk Ant Cervical >1 Seg 5/1/2018 Premera Blue Cross
63078 Exc Iv Disk Ant Thoracic-Ea Add Seg 5/1/2018 Premera Blue Cross
63082 Vert Corpectomy, Part/Comp.; anter. approach w/ decompression; cerv, each additional segment 5/1/2018 Premera Blue Cross
Contact for Review:
63086 Corpecto Verteb Thoracic Ea Add Seg 5/1/2018 Premera Blue Cross
63191 Section Spinal Accessory Nerve Unil 5/1/2018 Premera Blue Cross
63194 Cordotomy Unilat 1 Stage Cervical 5/1/2018 Premera Blue Cross
63195 Cordotomy Unilat 1 Stage Thoracic 5/1/2018 Premera Blue Cross
63196 Cordotomy Bilat 1 Stage Cervical 5/1/2018 Premera Blue Cross
63197 Laminect W Cordotomy;both Tracts;1 Stg;t 5/1/2018 Premera Blue Cross
63198 Cordotomy Bilat 2 Stage Cervical 5/1/2018 Premera Blue Cross
63266 Exc Les Intraspin Extradur- Thoracic 5/1/2018 Premera Blue Cross
63271 Exc Les Intraspin Intradur- Thoracic 5/1/2018 Premera Blue Cross
63275 Lam,Bx/Exc Intrasp.Neo;e xtra d ur, Ce r 5/1/2018 Premera Blue Cross
63276 Exc Intraspin Neopl Extradur- Thorac 5/1/2018 Premera Blue Cross
63281 Exc Intraspin Neopl Extramed- Thorac 5/1/2018 Premera Blue Cross
63285 Lam,Bx/Exc In.Neo;intrad ur, Im, Cerv 5/1/2018 Premera Blue Cross
63286 Exc Intraspin Neopl Intramed- Thorac 5/1/2018 Premera Blue Cross
63295 Osteoplastic Reconstruction of Dorsal Spinal Elements, Following Primary Intraspinal Procedure (List separately in addition to code for primary procedure)
63300 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical
63301 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach
63302 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach
63304 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical
63305 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach
63306 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach
63307 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach
63308 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment)
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63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
64480 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
866-666-0776
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64484 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
866-666-0776
866-666-0776
64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
866-666-0776
64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
866-666-0776
866-666-0776
64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
866-666-0776
64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or B513nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or s acral; third and any additional level(s) (List separately in addition to code for primary procedure)
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64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode a+B570rray and pulse generator 5/1/2018 Premera Blue Cross
64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 5/1/2018 Premera Blue Cross
64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) 5/1/2018 Premera Blue Cross
64595 Revision/removal of periph or gastric neurostimulator pulse generator or receiver 5/1/2018 Premera Blue Cross
64612 Dest Neurolytic Agent; Muscle Enervated 5/1/2018 Premera Blue Cross
64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
866-666-0776
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
866-666-0776
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
866-666-0776
64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
866-666-0776
64642 Chemodenervation of one extremity; 1-4 muscle(s) 5/1/2018 Premera Blue Cross
64643 Chemodenervation of one extremity; each additional extremity, 1 -4 muscle(s) (List separately in addition to code for primary procedure)
64644 Chemodenervation of one extremity; 5 or more muscle(s) 5/1/2018 Premera Blue Cross
64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure)
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) 5/1/2018 Premera Blue Cross
Contact for Review:
64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) 5/1/2018 Premera Blue Cross
64650 Chemodenervation of eccrine glands; both axillae 5/1/2018 Premera Blue Cross
64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 5/1/2018 Premera Blue Cross
66820 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) 4/1/2020
Premera Blue Cross Provider Portal 855-339-8127
66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages)
66830 Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo- scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) 4/1/2020
66840 Removal of lens material; aspiration technique, 1 or more stages
66852 Removal of lens material; pars plana approach, with or without vitrectomy
66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852) 4/1/2020 Premera Blue Cross
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage
67218 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source)
866-666-0776
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 5/1/2018 Premera Blue Cross
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) 5/1/2018 Premera Blue Cross
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) 5/1/2018 Premera Blue Cross
69930 Cochlear Device Implantation, W/Wo Masto 5/1/2018 Premera Blue Cross
70336 MRI of the Temporomandibular Joint(s) 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70450 CT of head, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70460 CT of head, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70470 CT of head, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70480 CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70481 CT of orbit, sella or posterior fossa and outer, middle or inner ear, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70482 CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70486 CT of maxillofacial area, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70487 CT of maxillofacial area, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70488 CT of maxillofacial area, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70490 CT, soft tissue neck, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70491 CT, soft tissue neck, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
70492 CT, soft tissue neck, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
70498 CTA, neck, with contrast material(s), including noncontrast images, if performed, and image post- processing 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70540 MRI orbit, face and neck, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70542 MRI orbit, face and neck, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70543 MRI orbit, face and neck, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
70545 Magnetic resonance angiography, head, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70546 Magnetic resonance angiography, head, without contrast, followed by re- imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70547 MRA, neck, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70548 MRA, neck, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70549 MRA, neck, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70551 MRI Head, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
70552 MRI Head, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70553 MRI Head, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) 1/1/2021 AIM Specialty Health AIM Provider Portal
866-666-0776
71275 CTA of chest (non-coronary), with contrast material(s), including noncontrast images, if performed, and image post- processing
866-666-0776
71550 MRI chest, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71551 MRI chest, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71552 MRI chest, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71555 MRA of chest (excluding the myocardium) without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
72125 CT of cervical spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72126 CT of cervical spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72127 CT of cervical spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72128 CT of thoracic spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72129 CT of thoracic spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72130 CT of thoracic spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72131 CT of lumbar spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72132 CT of lumbar spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72133 CT of lumbar spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72141 MRI of cervical spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72142 MRI of cervical spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72146 MRI of thoracic spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72147 MRI of thoracic spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
72148 MRI of lumbar spine, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72149 MRI of lumbar spine, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72156 MRI of cervical spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72157 MRI of thoracic spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72158 MRI of lumbar spine, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72159 Magnetic resonance angiography of spinal canal 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
72192 CT of pelvis, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72193 CT of pelvis, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72194 CT of pelvis without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72195 MRI of pelvis, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72196 MRI of pelvis, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72197 MRI of pelvis, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
73200 CT upper extremity, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73201 CT upper extremity, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73202 CT upper extremity, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
73218 MRI upper extremity, non-joint, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73219 MRI upper extremity, non-joint, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73220 MRI upper extremity, non-joint, without contrast, followed by re- imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73221 MRI upper extremity, any joint, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73222 MRI upper extremity, any joint, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73223 MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73225 Magnetic resonance angiography, upper extremity, without and with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73700 CT lower extremity without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
73701 CT lower extremity with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73702 CT lower extremity without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
73718 MRI lower extremity, other than joint, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73719 MRI lower extremity, other than joint, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73720 MRI lower extremity, other than joint, without contrast followed by re- imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73721 MRI lower extremity, any joint, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73722 MRI lower extremity, any joint, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73723 MRI lower extremity, any joint, without contrast followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73725 Magnetic resonance angiography, lower extremity, without and with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74150 CT abdomen; without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74160 CT abdomen; with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74170 CT abdomen; without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
74176 CT of abdomen and pelvis, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74177 CT of abdomen and pelvis, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74178 CT of abdomen and pelvis, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74181 MRI of abdomen, without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74182 MRI of abdomen, with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74183 MRI of abdomen, without contrast, followed by re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74185 Magnetic resonance angiography, abdomen; without or with contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74261 Diagnostic CT colonography without contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74262 Diagnostic CT colonography with contrast including non-contrast images if performed 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
74712 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation
866-666-0776
75557 Cardiac MRI for morphology and function, without contrast material 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75559 Cardiac MRI for morphology and function, without contrast material, with stress imaging 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75561 Cardiac MRI for morphology and function, without contrast material, followed by contrast material 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75563 Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress imaging 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75571 Computed tomography, heart, without contrast material, with quantitative evaluatio n of coronary artery calcium 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3-D image post-processing, assessment of cardiac function, and evaluation of venous structures if performed)
866-666-0776
75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3-D post-processing, assessment of left ventricular cardiac function, right ventricular structure and function and evaluation of venous structures, if performed)
866-666-0776
75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (where present), with contrast material, including 3-D image post- processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
866-666-0776
866-666-0776
76376 3D rendering w/ interpretationand reporting of CT MRI, US or other Tomographyic modality with image postprocessing under concurrent supervision
866-666-0776
76380 CT, limited or localized follow-up study 5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
76390 Magnetic Resonance Spectroscopy (MRS) 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
Contact for Review:
77014 CT guidance for placement of radiation therapy fields 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77046 MRI Breast Without Contrast Material Unilateral AIM Specialty Health
AIM Provider Portal 866-666-0776
77047 MRI Breast Without Contrast Material Bilateral AIM Specialty Health
77048 MRI Breast W/Out & With Contrast W/Cad Unilateral AIM Specialty Health
77049 MRI Breast Without & With Contrast W/Cad Bilateral AIM Specialty Health
77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
77084 MRI of bone marrow blood supply 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
77316 Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations (Do not bill 77300) 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77317 Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation (Do not bill 77300)
866-666-0776
77318 Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations (Do not bill 77300)
866-666-0776
866-666-0776
866-666-0776
77371 Radiation treatment delivery, stereotactic radiosurgery (SRS) complete course of treatment of cranial lesion(s) consisting of 1 session; multi -source Cobalt 60 based
866-666-0776
77372 Radiation treatment delivery, stereotactic radiosurgery (SRS) complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based
866-666-0776
77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
866-666-0776
77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed
866-666-0776
77402 Radiation treatment delivery, up to 5 MeV; simple. All of the following criteria are met (and none of the complex or intermediate criteria are met): single treatment area, one or two B699ports and two or fewer simple blocks
866-666-0776
77407 Radiation treatment delivery, up to 5 MeV; intermediate. Any of the following criteria are met (and none of the complex criteria are met): 2 separate treatment areas, 3 or more ports on a single treatment area, or 3 or more simple blocks
866-666-0776
77412 Radiation treatment delivery, up to 5 MeV; complex. Any of the following criteria are met: 3 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.
866-666-0776
77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77435 Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
866-666-0776
77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation) 1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Contact for Review:
77520 Proton beam delivery to a sgl treatment area, sgl port, custom block 5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
77523 Proton beam delivery to one or two treatment areas, two or more ports, two or more custom blocks 5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
77525 Proton Treatment Delivery; Complex 5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
866-666-0776
77767 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
866-666-0776
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)
866-666-0776
78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when B801performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
866-666-0776
78459 PET myocardial, metabolic evaluation 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78466 Planar, infarct avid; qualitative or quantitative 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78468 Planar, infarct avid; with ejection fraction by first pass technique 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78469 SPECT, infarct avid; with or without quantification 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78472 Gated equilibrium; planar, single study, wall motion plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78473 Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78481 First pass technique; single study, wall motion study plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78483 First pass technique; multiple studies, wall motion study plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78491 PET myocardial perfusion, single study 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78492 PET myocardial perfusion, multiple studies 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78494 Gated equilibrium: SPECT, at rest, wall motion study plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78608 PET brain, metabolic evaluation 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78609 PET brain, perfusion evaluation 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78811 PET imaging, limited area 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78812 PET imaging, skull to mid-thigh 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78813 PET imaging, whole body 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid- thigh 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovaria n cancer) gene analysis; full sequence analysis and full duplication/deletion analysis
81200 Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y2 31X) 5/1/2018 Premera Blue Cross
81201 APC (Adenomatous Polyposis Coli) Gene Analysis; Full Gene Sequence 5/1/2018 Premera Blue Cross
81202 APC (Adenomatous Polyposis Coli) Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
81205 Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta Polypeptide) Gene Analysis, Common Variants 5/1/2018 Premera Blue Cross
81210 Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg, Colon Cancer), Gene Analysis, V600E Variant 5/1/2018 Premera Blue Cross
81212 Brca1, Brca2 Gene Analysis; 185Delag, 5385Insc, 6174Delt Variants 5/1/2018 Premera Blue Cross
81215 Brca1 (Breast Cancer 1) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
81216 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81217 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
81225 Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypepti de 19), Gene Analysis, Common Variants 5/1/2018 Premera Blue Cross
81226 Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6), Gene Analysis, Common Variants 5/1/2018 Premera Blue Cross
81227 Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9), GeneAnalysis, Common Variants (Eg, -2, -3, -5, -6) 5/1/2018 Premera Blue Cross
Contact for Review:
81235 EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)
81243 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Evaluation To Detect Abnormal (Eg, Expanded) Alleles 5/1/2018 Premera Blue Cross
81244 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Characterization Of Alleles 5/1/2018 Premera Blue Cross
81255 Hexa (Hexosaminidase A [Alpha Polypeptide]) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S) 5/1/2018 Premera Blue Cross
81260 Inhibtr Of Kappa Light Plypeptide Gene Enhancr In B-Cells, Kinase Complex-Assoc Protein Gene Analysis, Common Variants
81275 Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13 5/1/2018 Premera Blue Cross
81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146)
81288 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non -polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis
Contact for Review:
81290 Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3- 2A>G, Del6.4Kb) 5/1/2018 Premera Blue Cross
81292 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analys is; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81293 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
81294 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
81295 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81296 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
81297 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
81298 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Full Sequence Analysi s 5/1/2018 Premera Blue Cross
81299 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
81300 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
81302 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81303 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
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81304 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
81311 NRAS (neuroblastoma RAS viral [v ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)
81317 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81318 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
81319 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Ana lysis; Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
81321 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
81322 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
81325 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
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81326 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
81332 Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha -1 Antiproteinase, Antitrypsin, Member 1), Gene Analysis,Common Variants
81355 Vkorc1 (Vitamin K Epoxide Re

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