Single source preauthorization list

This information is not a guarantee of payment.

Benefits are subject to limitations in a member’s Benefits Booklet (Certificate of Coverage) and the member’s eligibility status.

The information being provided is based on information currently available in Capital Blue Cross' files.

Payment or processing of actual claims is subject to a determination about the member’s benefits and eligibility at the time of processing and a determination that the services are medically necessary and appropriate. Other factors, including, but not limited to, outstanding or in-process claims, may affect actual totals. Information may change due to coverage alterations or cancellation. All information in our files is proprietary and confidential to Capital Blue Cross and is to be used only for its intended purposes.

Do not disclose

CPT and revenue code descriptions are subject to copyright and therefore not included on the external single source preauthorization code list.
Preauthorization is required for the following list of items that are not necessarily listed separately by code: all inpatient admissions or services/items that are considered by Capital Blue Cross medical policy to be investigational and possibly cosmetic.
Preauthorization is required for non-routine maternity admissions, including preterm labor, maternity complications, and newborns requiring continued hospitalization after the mother is discharged.
Preauthorization does not generally apply to services/items that are specifically excluded from coverage under the member’s Benefits Booklet (Certificate of Coverage). Therefore, these items may not appear on the preauthorization list.

All services that are considered investigational or possibly cosmetic require documentation from the member’s medical record to ensure the item/service is medically necessary. Certain services may also require submission of photographs and are noted below.
Please refer to Capital Blue Cross’ Medical Policy (or its delegated vendor) for medical necessity information.
Applied Behavioral Analysis (ABA) services requiring preauthorization are listed below on the Single Source Preauthorization Code list. Providers should submit the appropriate CPT codes listed below and no longer use H0032, H2014, H2019, H2020, H2021, and H2022 codes for ABA assessment or treatment.
Administrative services only (ASO)/ Self-funded groups: Please note that some self-funded employer groups may customize their plans with different benefits and preauthorization requirements. The provider can check authorization requirements at the service code level via the authorization portal.
Subject to the exceptions listed in the General Preauthorization Overview, codes requiring preauthorization are listed by code in this form.

Code	HCPCS and dental code description	Preauthorization category	Type of care	Comments	Commercial	Medicare Advantage
0023		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0552		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0314U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0001U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
0016U		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
0017U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
0018U		Investigational and experimental procedures	Diagnostic services : Genetic testing		Yes	No
0019U		Investigational and experimental procedures	Lab/Genetic testing	For Medicare covered if medically necessary	Yes	Yes
0022U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
0023U		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0026U		Diagnostic services/Genetic testing	Lab/Genetic testing		Yes	No
0027U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0029U		Lab/Genetic testing	Lab/Genetic testing		Yes	No
0034U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0035U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0037U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0040U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0042T		Diagnostic services: CT scans	X-ray/Imaging - Cat scan	This service is preauthorized through Evolent. Traditional Products do not require preauthorization	Yes	Yes
0046U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
0047U		Diagnostic services: Genetic testing	Investigational lab/Genetic testing	Non covered for commercial product	Yes	Yes
0049U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
0069U		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
0084U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
0094U		Diagnostic services: Genetic testing	Lab/Genetic Testing		Yes	Yes
0111U		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
0138U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0152U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0153U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0154U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0155U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0157U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0158U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0159U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0160U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0161U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0162U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0165T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0169U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0171U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0172U		Lab/Genetic testing	Lab/Genetic testing		Yes	No
0173U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0177U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0180U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0181U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0182U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0183U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0184U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0185U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0186U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0187U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0188U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0189U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0190U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0191U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0192U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0193U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0194U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0195U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0196U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0197U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0198U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0199U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0200T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0200U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0201T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0201U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0202T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0209U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0245U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0253T		Outpatient surgery for select procedures	Surgery - eye		Yes	No
0286U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0212U		Diagnostic services: MRI	Diagnostic services: MRI		Yes	Yes
0213U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0214U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0215U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0218U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0219T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0220T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0221T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0222T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0230U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0231U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0232U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet the medically necessary criteria on policy then invalid	Yes	Yes
0233U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0234U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet the criteria on 2.326	Yes	Yes
0235U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0237U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
0238U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet criteria on policy then invalid	Yes	No
0239U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
0250U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0252U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
0258U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0260U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0264U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0265U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0266U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0267U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0268U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0269U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0270U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0271U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0272U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0273U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0274U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0277U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0278U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0282U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0274T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0275T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0129U	Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53)	Diagnostic services: genetic testing	Lab/genetic testing		Yes	Yes
0276U	Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid	Diagnostic services: genetic testing	Lab/genetic testing		Yes	Yes
0317U	Oncology (lung cancer), four-probe fish (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithm generated evaluation reported as decreased or increased risk for lung cancer	Diagnostic services: genetic testing	Diagnostic services: genetic testing		Yes	Yes
0318U	Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood	Diagnostic services: genetic testing	Diagnostic services: genetic testing		Yes	Yes
0326U		Diagnostic services: genetic testing	Diagnostic services: genetic testing		Yes	Yes
0334U		Diagnostic services: genetic testing	Lab/genetic testing		Yes	Yes
0335U		Diagnostic services: genetic testing	Lab/genetic testing		Yes	Yes
0336U		Diagnostic services: genetic testing	Lab/genetic testing		Yes	Yes
0345T		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
0362T		Investigational and experimental procedures	Applied behavior analysis (ABA)		Yes	No
0364U		Diagnostic Services: Genetic Testing	Diagnostic Services: Genetic Testing		Yes	Yes
0373T		Investigational and experimental procedures	Applied behavior analysis (ABA)		Yes	No
0378U		Diagnostic Services: Genetic Testing	Diagnostic Services: Genetic Testing		Yes	Yes
0388U	Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection	Diagnostic Services: Genetic Testing	Lab/Genetic testing		Yes	Yes
0394T		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
0461U	Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (snp) genotyping by real-time pcr of 24 genes, whole blood or buccal swab, with variant analysis, including impacted gene-drug interactions and reported phenotypes	Diagnostic Services: Genetic Testing	Lab/Genetic Testing		Yes	Yes
0471U	oncology (colorectal cancer), qualitative real-time pcr of 35 variants of kras and nras genes (exons 2,3,4), formalin-fixed paraffin-embedded (ffpe), predictive, identification of detected mutations	Diagnostic Services: Genetic Testing	Lab/Genetic Testing		Yes	Yes
0473U	oncology (solid tumor), next-generation sequencing (ngs) of dna from formalin-fixed paraffin-embedded (ffpe) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden	Diagnostic Services: Genetic Testing	Lab/Genetic Testing		Yes	Yes
0474U	hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with 20 duplications/deletions using next-generation sequencing (ngs), sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene	Diagnostic Services: Genetic Testing	Lab/Genetic Testing		Yes	Yes
0481U	IDH1 (Isocitrate Dehydrogenase 1 [NADP+]), IDH2 (Isocitrate Dehydrogenase 2 [NADP+]), And TERT (Telomerase Reverse Transcriptase) Promoter (Eg, Central Nervous System [CNS] Tumors), Next-Generation Sequencing (Single-Nucleotide Variants [SNV], Deletions, And Insertions)	Diagnostic Services: Genetic Testing	Lab/Genetic Testing		Yes	No
0395T		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
0402T		Outpatient Surgery For Select Procedures	Surgery - Eye		No	Yes
0417U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0449U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	No
0441T		New to market service	New Technology		Yes	Yes
0449T		Investigational and experimental procedures	Investigational eye procedures		Yes	No
0450T		Investigational and experimental procedures	Investigational eye procedures		Yes	No
0474T		Investigational and experimental procedures	Investigational eye procedures		Yes	No
0483T		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
0524T		Reconstructive or cosmetic services: Varicose veins	Varicose vein procedure		Yes	Yes
0552T		other services: laser treatment	Wound care		Yes	Yes
0570		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0571		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0572		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0579		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0580		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0581		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0582		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0583		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0589		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0590		Other services: Home health care	Home health care	Facility revenue code requires preauthorization.	Yes	Yes
0624		Investigational and experimental procedures	Investigational Supply	Facility revenue code requires preauthorization.	Yes	Yes
0671T		Investigational and experimental procedures	Investigational eye procedures		Yes	No
0724T		Diagnostic Services es: mri	X-RAY/Imaging-mri	This service is preauthorized through Evolent	Yes	Yes
0742T		Diagnostic Services es: spect	X-RAY/Imaging-Spect	This service is preauthorized through Evolent	Yes	Yes
0784T		Surgery for select procedures	Surgery - musculoskeletal	This service is preauthorized through Turning Point.	Yes	No
0785T		Surgery for select procedures	Surgery - musculoskeletal	This service is preauthorized through Turning Point.	Yes	No
0786T		Surgery for select procedures	Nerve stimulator	;	Yes	No
0787T		Surgery for select procedures	Nerve stimulator	;	Yes	No
0790T		Surgery for select procedures	Surgery - musculoskeletal	This service is preauthorized through Turning Point.	Yes	No
0905		Select outpatient behavioral health services	Behavioral health service		Yes	Yes
0906		Select outpatient behavioral health services	Behavioral health service		Yes	Yes
0912		Select outpatient behavioral health services	Behavioral health service		Yes	Yes
0913		Select outpatient behavioral health services	Behavioral health service		Yes	Yes
10040		Reconstructive or cosmetic services: Acne surgery	Surgery - skin procedure		Yes	Yes
11450		Reconstructive or cosmetic services: excision/lipectomy	Surgery-skin procedure		Yes	Yes
11451		Reconstructive or cosmetic services: excision/lipectomy	Surgery-skin procedure		Yes	Yes
11920		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
11921		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
11950		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11951		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11952		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11954		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11960		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11970		Other services: Bio-engineered skin or biological wound care	Skin procedure	Preauthorization not required for treatment of cancer.	Yes	Yes
11971		Other services: Bio-engineered skin or biological wound care	Skin procedure	Preauthorization not required for treatment of cancer.	Yes	Yes
15150		Other services: wound care products	Wound care		Yes	Yes
15155		Other services: wound care products	Wound care		Yes	Yes
15271		Other services: wound care products	Wound care		Yes	No
15273		Other services: wound care products	Wound care		Yes	No
15275		Other services: wound care products	Wound care		Yes	No
15277		Other services: wound care products	Wound care		Yes	No
15771		Reconstructive or cosmetic services: Breast procedures	Reconstructive or cosmetic services: Augmentation and grafting		Yes	Yes
15773		Surgery for select procedures	Reconstructive or cosmetic services:		Yes	Yes
15775		Reconstructive or cosmetic services: Hair transplant	Hair transplant		Yes	Yes
15776		Reconstructive or cosmetic services: Hair transplant	Hair transplant		Yes	Yes
15780		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	No
15781		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	No
15782		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	No
15783		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	No
15786		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	Yes
15788		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	Yes
15789		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	Yes
15792		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	Yes
15793		Reconstructive or cosmetic services: Dermabrasion	Skin procedure		Yes	Yes
15820		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
15821		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
15822		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
15823		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
15824		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15825		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15826		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15828		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15829		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15830		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	No
15832		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15833		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15834		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15835		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15836		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15837		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15838		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15839		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15876		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15877		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	No
15878		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15879		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
17106		Other services: Laser treatment	Skin procedure		Yes	No
17107		Other services: Laser treatment	Skin procedure		Yes	No
17108		Other services: Laser treatment	Skin procedure		Yes	No
17360		Reconstructive or cosmetic services: Acne surgery	Skin procedure		Yes	Yes
17380		Reconstructive or cosmetic services: Acne surgery	Surgery - Heart/Blood vessel		Yes	Yes
19296		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
19297		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
19298		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
19300		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19316		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19318		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19325		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19328		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19330		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19340		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19342		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19350		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
19355		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19357		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19361		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19364		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19367		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19368		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19369		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19370		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19371		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19380		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19396		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	No
20605		Office surgical procedures	Injection procedure	Requires preauthorization only when performed in a facility.	Yes	No
20974		Investigational and experimental procedures	Bone stimulator		Yes	Yes
20975		Investigational and experimental procedures	Bone stimulator		Yes	Yes
20979		Investigational and experimental procedures	Bone stimulator		Yes	Yes
20982		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
21073		Investigational and experimental procedures	Investigational TMJ treatment		Yes	Yes
21116		Office surgical procedures	Injection procedure	Requires preauthorization only when performed in a facility.	Yes	No
21120		Other services: Augmentation and Grafting	Surgery - Head/Face		Yes	Yes
21121		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21122		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21123		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21125		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21127		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21137		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21138		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21139		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21141		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21142		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21143		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21145		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21146		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21147		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21150		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21151		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21154		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21155		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21159		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21160		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21172		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21175		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21179		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21180		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21181		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21182		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21183		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21184		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21188		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21193		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21194		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21195		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21196		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21198		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21199		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21206		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21208		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21209		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21210		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21215		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21230		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21235		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21240		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	No
21242		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	No
21243		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	No
21244		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21245		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21246		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21247		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21248		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21249		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21255		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21256		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21263		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21267		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21268		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21270		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21275		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21280		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Eye		Yes	Yes
21282		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Eye		Yes	Yes
21431		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21432		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21433		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21435		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21436		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Head/Face		Yes	Yes
21740		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Chest		Yes	Yes
21742		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Chest		Yes	Yes
21743		Reconstructive or cosmetic services: Augmentation and grafting	Surgery - Chest		Yes	Yes
22220		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22222		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22224		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22226		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22510		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22511		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22512		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22513		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22514		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22515		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22532		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22533		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22534		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22548		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22551		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22552		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22554		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22556		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22558		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22585		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22586		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22590		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22595		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22600		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22610		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22612		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22614		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22630		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22632		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22633		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22634		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22800		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22802		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22804		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22808		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22810		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22812		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22818		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22819		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22830		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22836		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
22837		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
22838		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
22849		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22856		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22857		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22858		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22860		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through Turning Point	Yes	Yes
22861		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22862		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22864		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22865		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22867		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22868		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22869		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22870		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22899		Surgery for select procedures	Musculoskeletal Procedures	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23120		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider.	Yes	Yes
23125		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23130		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23190		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23195		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23333		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23334		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23335		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23395		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23397		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23400		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23405		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23406		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23410		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23412		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23415		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23420		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23440		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23450		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23455		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23460		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23462		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23465		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23466		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23470		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23472		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23473		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23474		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23616		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23800		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23802		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27033		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27090		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27091		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27120		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27122		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27125		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27130		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27132		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27134		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27137		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27138		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27146		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27147		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27151		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27156		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27158		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27161		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27236		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27278		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
27279		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27280		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27284		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27286		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27299		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27403		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27405		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27407		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27409		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27412		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27415		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27416		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27418		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27420		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27422		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27424		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27425		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27427		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27428		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27429		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27437		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27438		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27440		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27441		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27442		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27443		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27445		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27446		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27447		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27486		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27487		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27488		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27570		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27580		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
28291		Hallux Rigidus Correction With Cheilectomy, Debridement And Capsular Release Of The First Metatarsophalangeal Joint; With Implant	Outpatient Surgery For Select Procedures	Surgery- Musculoskeletal	Yes	No
28446		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29827		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29850		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29851		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29855		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29856		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29860		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29861		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29862		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29863		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29866		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29867		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29868		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29870		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29871		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29873		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29874		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29875		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29876		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29877		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29879		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29880		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29881		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29882		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29883		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29884		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29885		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29886		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29887		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29888		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29889		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29914		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29915		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29916		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29999		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider.	Yes	Yes
30400		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30410		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
0425U		Diagnostic Services: Genetic Testing	Lab/genetic testing		Yes	Yes
0426U		Diagnostic Services: Genetic Testing	Lab/genetic testing		Yes	Yes
30420		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30430		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30435		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30450		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30460		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30462		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30520		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30620		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	Yes
31295		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses	11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31296		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses	11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31297		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses	11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31298		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	Yes
31574		Reconstructive	Injection procedure		Yes	Yes
31591		Investigational and experimental procedures	Reconstructive or cosmetic services		Yes	Yes
31660		Surgery for select procedures	Surgery - Lung		Yes	Yes
31661		Surgery for select procedures	Surgery - Lung		Yes	Yes
32664		Surgery for select procedures	surgery-musculoskeletal		Yes	Yes
32850		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32851		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32852		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32853		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32854		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32855		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32856		Transplant surgeries	Organ/Tissue transplant - Lung		Yes	Yes
32998		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
33270		Investigational and experimental procedures	Investigational heart procedures		Yes	No
33271		Investigational and experimental procedures	Investigational heart procedures		Yes	No
33273		Investigational and experimental procedures	Investigational heart procedures		Yes	No
33285		Outpatient surgery: Elective cardiac procedures	Surgery - Heart/Blood vessel		Yes	Yes
33361		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33362		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33363		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33364		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33365		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33366		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33418		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33419		Outpatient surgery for select procedures	Surgery - Heart valve		Yes	Yes
33477		Outpatient surgery for select procedures	Surgery-heart valve		Yes	Yes
33927		Transplant surgeries	Organ/Tissue transplant - Heart		Yes	Yes
33928		Transplant surgeries	Organ/Tissue transplant - Heart		Yes	No
33930		Transplant surgeries	Organ/Tissue transplant - Heart/Lung		Yes	Yes
33933		Transplant surgeries	Organ/Tissue transplant - Heart/Lung		Yes	Yes
33935		Transplant surgeries	Organ/Tissue transplant - Heart/Lung		Yes	Yes
33940		Transplant surgeries	Organ/Tissue transplant - Heart		Yes	Yes
33944		Transplant surgeries	Organ/Tissue transplant - Heart		Yes	Yes
33945		Transplant surgeries	Organ/Tissue transplant - Heart		Yes	Yes
33975		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33976		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33977		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33978		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33979		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	No
33980		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	No
33981		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33982		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
33983		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34701		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34702		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34703		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34704		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34705		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34706		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34707		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
34708		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	Yes
36465		Reconstructive or cosmetic services: Varicose veins	Varicose vein procedure		Yes	No
36466		Reconstructive or cosmetic services: Varicose veins	Varicose vein procedure		Yes	No
36468		Reconstructive or cosmetic services: Varicose veins	Vein procedures		Yes	No
36470		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
36471		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
36475		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
36478		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
36482		Outpatient surgery for select procedures	Surgery - Heart/Blood vessel		Yes	No
37500		Reconstructive or cosmetic services: Varicose veins	Vein procedures		Yes	No
37700		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37718		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37722		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37735		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37760		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37761		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37765		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37766		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37780		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
37785		Reconstructive or cosmetic services: Varicose veins	Surgery - Varicose vein		Yes	No
38205		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38206		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38207		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38208		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38209		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38210		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38211		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38212		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38213		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38214		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38215		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38230		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38232		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38240		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38241		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38242		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38243		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
43229		Outpatient surgery for select procedures	Gastrointestinal procedure	Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia	Yes	No
43270		Outpatient surgery for select procedures	Gastrointestinal procedure	Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia	Yes	No
43644		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43645		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43647		Outpatient services: bariatric surgery	Surgery – Weight loss		Yes	Yes
43648		Outpatient services: bariatric surgery	Surgery – Weight loss		Yes	Yes
43659		Outpatient surgery for select procedures	Surgery - Stomach and intestines		Yes	No
43770		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43771		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43772		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43773		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43774		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43775		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43842		Investigational and experimental procedures	Investigational Weight Loss Surgery		Yes	No
43843		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43845		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43846		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43847		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43848		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43881		Outpatient services: Bariatric surgery	Surgery – Weight loss		Yes	Yes
43882		Outpatient services: Bariatric surgery	Surgery – Weight loss		Yes	Yes
43886		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43887		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
43888		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	No
44132		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	No
44133		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	No
44135		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	No
44136		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	No
44715		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	Yes
44720		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	Yes
44721		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	Yes
47133		Transplant surgeries	Organ/Tissue transplant - Intestine		Yes	Yes
47135		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47140		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47141		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47142		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47143		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47144		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47145		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47146		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47147		Transplant surgeries	Organ/Tissue transplant - Liver		Yes	Yes
47370		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
47380		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
47382		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
48160		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	No
48550		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	Yes
48551		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	Yes
48552		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	Yes
48554		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	No
48556		Transplant surgeries	Organ/Tissue transplant - Pancreas		Yes	Yes
50300		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50320		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50323		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50325		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50327		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50328		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50329		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50340		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50360		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50365		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50380		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50542		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
50547		Transplant surgeries	Organ/Tissue transplant - Kidney		Yes	Yes
50592		Outpatient surgery for select procedures	Tumor Ablations		Yes	Yes
52441		Investigational and experimental procedures	Investigational bladder procedure		Yes	Yes
52442		Investigational and experimental procedures	Investigational bladder procedure		Yes	Yes
60660		Outpatient surgery for select procedures	Surgery - Head/Face		Yes	No
60661		Outpatient surgery for select procedures	Surgery - Head/Face		Yes	No
61863		Outpatient surgery for select procedures	Surgery - Head/Face		Yes	Yes
61867		Outpatient surgery for select procedures	Surgery - Head/Face		Yes	Yes
61880		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
61885		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
61886		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
61888		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
61889		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
61891		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
61892		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
62287		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63001		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63003		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63005		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63011		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63012		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63015		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63016		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63017		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63020		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63030		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63035		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63040		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63042		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63043		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63044		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63045		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63046		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63047		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63048		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63050		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63051		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63052		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63053		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63055		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63056		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63057		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63064		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63066		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63075		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63076		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63077		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63078		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63081		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63082		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63085		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63086		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63087		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63088		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63090		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63091		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63101		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63102		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63103		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63170		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63172		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63173		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63185		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63190		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63191		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63194		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63195		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63196		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63197		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63198		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63199		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63200		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63250		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63251		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63252		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63265		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63266		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63267		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63268		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63270		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63271		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63272		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63273		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63275		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63276		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63277		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63278		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63280		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63281		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63282		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63283		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63285		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63286		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63287		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63290		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63295		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63300		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63301		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63302		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63303		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63304		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63305		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63306		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63307		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63308		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63650		Nerve stimulators and devices	Nerve stimulator		Yes	No
63655		Nerve stimulators and devices	Nerve stimulator		Yes	No
63685		Nerve stimulators and devices	Nerve stimulator		Yes	No
64553		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64561		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64566		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
64568		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64569		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64570		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64580		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64581		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64582		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
64583		Outpatient surgery for select procedures	Nerve stimulator		Yes	No
64596		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64598		Outpatient surgery for select procedures	Nerve stimulator		Yes	Yes
64633		Investigational and experimental procedures	Investigational Nerve Procedure		Yes	No
64635		Outpatient surgery for select procedures	Nerve Procedures		Yes	No
64640		Office surgical procedures	Injection procedure	Requires preauthorization only when performed in a facility.	Yes	Yes
65756		Outpatient surgery for select procedures	Surgery - Eye		No	Yes
65781		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
65782		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
65785		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
66179		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
66180		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
66183		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
66184		Investigational and experimental procedures	Investigational eye procedures		Yes	Yes
66989		Investigational and experimental procedures	Investigational eye procedures		Yes	No
66991		Investigational and experimental procedures	Investigational eye procedures		Yes	No
67900		Reconstructive or cosmetic services: Ptosis repair	Surgery - Eyelid		Yes	No
67901		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67902		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67903		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67904		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67906		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67908		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
67909		Reconstructive or cosmetic services: Ptosis repair	Surgery - Eyelid		Yes	No
67911		Reconstructive or cosmetic services: Ptosis repair	Surgery - Eyelid		Yes	No
69300		Reconstructive or cosmetic services: Otoplasty	Surgery - Head/Face		Yes	Yes
69676		Surgery for select procedures	Surgery - Head/Face		Yes	Yes
69710		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69711		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69714		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69716		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69717		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69719		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69726		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69727		Outpatient surgery for select procedures	Hearing testing and treatment		Yes	Yes
69728		Dme: implantable device	Hearing testing and treatment		Yes	Yes
69729		Dme: implantable device	Hearing testing and treatment		Yes	Yes
69730		Surgery for select procedures	Hearing testing and treatment		Yes	Yes
69930		Surgery for select procedures	Hearing testing and treatment		Yes	No
70336		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70450		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70460		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70470		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70480		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70481		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70482		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70486		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70487		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70488		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70490		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70491		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70492		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70496		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70498		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70540		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70542		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70543		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70544		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70545		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70546		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70547		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70548		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70549		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70551		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70552		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70553		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70554		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
70555		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
71250		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent.	Yes	Yes
71260		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent.	Yes	Yes
71270		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent.	Yes	Yes
71271		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This services is preauthorized through Evolent. Traditional Products do not require Preauth	Yes	No
71275		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
71550		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
71551		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
71552		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
71555		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72125		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72126		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72127		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72128		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72129		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72130		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72131		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72132		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72133		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72141		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72142		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72146		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72147		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72148		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72149		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72156		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72157		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72158		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72159		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72191		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72192		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72193		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72194		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72195		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72196		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72197		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
72198		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73200		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73201		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73202		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73206		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73218		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73219		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73220		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73221		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73222		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73223		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73225		Diagnostic services: MRI	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73700		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73701		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73702		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73706		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73718		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73719		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73720		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73721		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73722		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73723		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
73725		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74150		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74160		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74170		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74174		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74175		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74176		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74177		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74178		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74181		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74182		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74183		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74185		Diagnostic services: MRI	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74261		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74262		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74263		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	No
74712		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
74713		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75557		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75559		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75561		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75563		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75565		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75571		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75572		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
75573		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. Traditional Products do not require preauthorization.	Yes	Yes
75635		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
76380		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
76390		Diagnostic services: SPECT	Nuclear medicine testing - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
77014		Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
77046		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
77047		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
77048		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
77049		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
77084		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
77280		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77285		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77290		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77295		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77300		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77301		Reconstructive or cosmetic services: Breast procedures	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77306		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77307		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77316		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77317		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77318		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77321		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77331		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77332		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77333		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77334		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77336		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77338		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77370		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77371		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77372		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77373		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77385		Therapy services: Radiation therapy , IMRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77386		Therapy services: Radiation therapy , IMRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77387		Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77399		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77401		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77402		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77407		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77412		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77417		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77423		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77424		Therapy services: Radiation therapy ,IORT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77425		Therapy services: Radiation therapy ,IORT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77427		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77431		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77432		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77435		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77469		Therapy services: Radiation therapy ,IORT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77470		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77499		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77520		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77522		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77523		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77525		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77600		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77605		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77610		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77615		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77620		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77761		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77762		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77763		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77767		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77768		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77770		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77771		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77772		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77778		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77789		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77790		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
77799		Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
78429		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78430		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78431		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78432		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78433		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78434		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78451		Diagnostic services: SPECT	X-Ray/Imaging -SPECT	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78452		Diagnostic services: SPECT	X-Ray/Imaging -SPECT	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78453		Diagnostic services: Cardiac Nuclear Medicine Studies	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78454		Diagnostic services: Cardiac Nuclear Medicine Studies	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78459		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78466		Diagnostic services: Cardiac Nuclear Medicine Studies	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78468		Diagnostic services: Cardiac Nuclear Medicine Studies	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78469		Outpatient surgery: Elective cardiac procedures	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78472		Diagnostic services: MUGA	Nuclear medicine testing - heart	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78473		Diagnostic services: MUGA	Nuclear medicine testing - heart	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78481		Outpatient surgery: Elective cardiac procedures	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78483		Outpatient surgery: Elective cardiac procedures	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78491		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78492		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78494		Diagnostic services: MUGA	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78496		Diagnostic services: MUGA	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78499		Diagnostic services: Cardiac Nuclear Medicine Studies	X-Ray/Imaging - Heart studies	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78608		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78609		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78803		Diagnostic services: spect	X-Ray/Imaging -SPECT	This service is preauthorized through Evolent. Traditional Products do not require Preauth	Yes	Yes
78811		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78812		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
78813		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78814		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78815		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78816		Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
78830		diagnostic services: spect	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. Traditional Products do not require Preauth	Yes	Yes
78831		diagnostic services: spect	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. Traditional Products do not require Preauth	Yes	Yes
78832		diagnostic services: spect	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. Traditional Products do not require Preauth	Yes	Yes
81105		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81106		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81107		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81108		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81109		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81110		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81111		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81112		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81120		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81121		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81161		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81162		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81163		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81164		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81165		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81166		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81167		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81168		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81170		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81173		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81174		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81175		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81176		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81177		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81178		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81179		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81180		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81181		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81182		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81183		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81184		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81185		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81186		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81187		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81188		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81189		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81190		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81191		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81192		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81193		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81194		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81200		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81201		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81202		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81203		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81204		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81205		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81206		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81207		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81208		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81209		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81210		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81212		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81215		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81216		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81217		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	No
81218		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81221		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81222		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81223		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81224		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81226		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81227		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81228		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81229		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81232		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81233		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81234		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81235		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81236		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81237		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81238		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81239		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81240		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81241		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81242		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81243		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81244		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81245	Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; dna analysis or combined dna and rna analysis	Lab/Genetic testing	Lab/Genetic testing		Yes	No
81246		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81250		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81251		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81252		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81253		Diagnostic services: Genetic testingg	Lab/Genetic testing		Yes	No
81254		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81255		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81256		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81257		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81258		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81259		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81260		Lab/Genetic testing	Diagnostic services : Genetic testing		Yes	No
81261		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81262		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81263		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81264		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81265		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81266		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81269		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81270		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81271		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81272		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81273		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81274		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81275		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81276		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81277		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81278		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81283		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81284		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81285		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81286		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81288		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81289		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81290		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81292		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81293		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81294		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81295		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81296		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81297		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81298		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81299		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81300		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81301		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81302		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81303		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81304		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81305		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81306		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81307		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81308		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81309		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81310		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81311		Investigational and experimental procedures	Investigational lab/Genetic testing		Yes	No
81312		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81314		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81315		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81316		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81317		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81318		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81319		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81320		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81321		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81322		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81323		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81324		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81325		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81326		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81327		Investigational and experimental procedures	Investigational lab/Genetic testing		Yes	No
81328		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81330		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81331		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81332		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81333		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81334		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81335		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81336		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81337		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81340		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81341		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81342		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81343		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81344		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81345		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81347		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81348		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81349		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81350		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81351		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81352		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81353		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81357		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81360		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81361		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81362		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81363		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81364		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81400		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81401		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81402		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81403		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81404		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81405		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81406		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81407		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81408		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81410		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81411		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81412		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81413		Investigational and experimental procedures	Investigational lab/Genetic testing		Yes	No
81414		Investigational and experimental procedures	Investigational lab/Genetic testing		Yes	No
81415		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81416		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81417		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81418		Lab/Genetic testing	Lab/Genetic testing		No	Yes
81419		Diagnostic Services: Genetic Testing c	Lab/Genetic testing		Yes	Yes
81425		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81426		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81427		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81430		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81431		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81432		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81434		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81435		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	Yes
81437		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	Yes
81439		Investigational and experimental procedures	Investigational lab/Genetic testing		Yes	No
81440		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81441		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81442		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81443		Lab/Genetic testing	Lab/Genetic testing		Yes	No
81445		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81448		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81450		Diagnostic services: genetic testing	lab/Genetic testing	;	Yes	Yes
81451		Investigational and experimental procedures	Investigational lab/Genetic testing	Non covered for commercial product	No	Yes
81455		Diagnostic services: genetic testing	lab/Genetic testing		Yes	No
81456		Investigational and experimental procedures	Investigational lab/Genetic testing	Non covered for commercial product	No	Yes
81457		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81458		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81459		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81460		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81462		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81463		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81464		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	No
81465		Diagnostic services : Genetic testing	Lab/Genetic testing		Yes	No
81470		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81471		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81479		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81493		Diagnostic services: Genetic testing	Lab/Genetic testing	Non covered for commercial product	No	Yes
81500		Diagnostic services: Genetic testing	Lab/Genetic testing		No	Yes
81538		Diagnostic services: Genetic testing	Lab/Genetic testing	5/1/2016 effective for Preauth.	Yes	Yes
81540		Diagnostic services: Genetic testing	Lab/Genetic testing	5/1/2016 effective for Preauth.	Yes	Yes
81541		Diagnostic services: Genetic testing	Lab/Genetic testing	Non covered for commercial product	Yes	Yes
81542		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81546		Diagnostic services: Genetic testing	Lab/Genetic testing	If test does not meet criteria in the policy, it would be invalid	Yes	No
81552		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
85300		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85301		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85302		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85303		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85305		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85306		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
85307		Diagnostic services: genetic testing	Lab/Genetic testing		Yes	Yes
86152		Investigational and experimental procedures	Investigational lab test		Yes	Yes
86153		Investigational and experimental procedures	Investigational lab test		Yes	Yes
87900		Investigational and experimental procedures	LAB test		Yes	Yes
87901		Investigational and experimental procedures	LAB test		Yes	Yes
87903		Investigational and experimental procedures	LAB test		Yes	Yes
87906		Investigational and experimental procedures	LAB test		Yes	Yes
88240		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
88249		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88261		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88263		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88271		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88272		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88273		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88274		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88275		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
88291		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
90281		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90283		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90284		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90378		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90587		Medical Injectables/Other Non-Injectable Drug	Medical Specialty Drug		Yes	No
90867		Select outpatient behavioral health services	Investigational Nerve stimulator		Yes	Yes
90868		Select outpatient behavioral health services	Investigational Nerve stimulator		Yes	Yes
90869		Select outpatient behavioral health services	Investigational Nerve stimulator		Yes	Yes
93228		Investigational and experimental procedures	Investigational and experimental procedures		Yes	No
93229		Investigational and experimental procedures	Investigational and experimental procedures		Yes	No
93303		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93304		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93306		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93307		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93308		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93312		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93313		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93314		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93315		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93316		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93317		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93318		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93350		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93351		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
93352		Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
95805		Other services: Sleep studies facility based	Sleep studies		Yes	No
95807		Other services: Sleep studies facility based	Sleep studies		Yes	No
95808		Other services: Sleep studies facility based	Sleep studies		Yes	No
95810		Other services: Sleep studies facility based	Sleep studies	Preauthorization is not required for pediatrics less than 18 years of age.	Yes	No
95811		Other services: Sleep studies facility based	Sleep studies	Preauthorization is not required for pediatrics less than 18 years of age.	Yes	No
95930		Investigational and experimental procedures	Brain testing		Yes	No
96920	>	Outpatient surgery for select procedures	Treatment of skin diseases		Yes	Yes
96921	>	Outpatient surgery for select procedures	Treatment of skin diseases		Yes	Yes
96922	>	Outpatient surgery for select procedures	Treatment of skin diseases		Yes	Yes
97037		Other services: laser treatment	Investigational laser therapy		Yes	No
97151		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97152		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97153		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97154		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97155		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97156		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97157		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
97158		Select outpatient behavioral health services	Applied behavior analysis (ABA)		Yes	No
A0430	Ambulance service, conventional air services, transport, one way (fixed wing)	Office surgical procedures	Non emergency ambulance transport		Yes	Yes
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)	Other services: Ambulance services -Non Emergent	Non emergency ambulance transport		Yes	Yes
A0435	Fixed wing air mileage, per statute mile	Other services: Ambulance services -Non Emergent	Non emergency ambulance transport		Yes	Yes
A0436	Rotary wing air mileage, per statute mile	Other services: Ambulance services -Non Emergent	Non emergency ambulance transport		Yes	Yes
A4560	Neuromuscular electrical stimulator (NMES), disposable, replacement only	Nerve stimulators & devices	Nerve stimulators		Yes	Yes
A4290	Sacral Nerve stimulation test lead, each	Investigational and experimental procedures	Nerve stimulator		Yes	Yes
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories	Diabetic DME & supplies	DME supplies		Yes	No
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system	Diabetic DME & supplies	Diabetic Supplies		Yes	No
A9513	Lutetium LU 177, dotatate, therapeutic, 1 millicurie	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
A9590	Iodine i-131, Iobenguane, 1 mCi	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
A9607	Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 mci	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4150	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4152	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4161	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B4162	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: enteral feeding and supplies	Special nutrient formula		Yes	No
B9002	Enteral nutrition infusion pump - any type	Other services: enteral feeding and supplies	Special nutrient formula		Yes	Yes
B9998	NOC for enteral supplies	Other services: enteral feeding and supplies	DME supplies		Yes	No
C1764	Event recorder, cardiac (implantable)	DME: implant	DME Implant		Yes	Yes
C1767	Generator, neurostimulator (implantable), non-rechargeable	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C1772	Infusion pump, programmable (implantable)	DME: implant	DME pump		Yes	Yes
C1778	Lead, neurostimulator (implantable)	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C1783	Ocular implant, aqueous drainage assist device	DME: prosthetic appliances and implants	Prosthetic devices	Facility code requires preauthorization	Yes	Yes
C1787	Patient programmer neurostimulator	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C1789	Prosthesis, breast (implantable)	Reconstructive or cosmetic services - breast procedures	Surgery - breast	Preauthorization not required for treatment of cancer.	Yes	Yes
C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system	Investigational and experimental procedures	Investigational and experimental procedures	Facility code requires preauth	Yes	Yes
C1821	Interspinous process distraction device (implantable)	DME: prosthetic appliances and implants	Prosthetic devices	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
C1822	Generator, neurostimulator (implantable), high frequency , with rechargeable battery and charging system	Investigational and experimental procedures	Investigational Procedure	Facility code requires preauthorization	Yes	Yes
C1839	Iris prosthesis	DME: Prosthetic appliances and implants	Eye procedure		Yes	No
C1883	Adaptor/extension, pacing lead or neurostimulator lead (implantable)	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C1891	Infusion pump, Nonprogrammable, permanent (implantable)	DME: implant	DME pump		Yes	Yes
C1897	Lead, neurostimulator test kit (implantable)	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C2616	Brachytherapy source, non-stranded, YTTRIUM-90, per source	Therapy services: Radiation therapy	Radiation therapy	Facility code requires preauthorization. This service is preauthorized through Evolent. *Traditional Products do not require preauthorization	Yes	Yes
C2626	Infusion pump, Nonprogrammable, temporary (implantable)	DME: implant	DME pump	Facility code requires preauthorization	Yes	Yes
C8900	Magnetic Resonance Angiography with contrast, abdomen	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8901	Magnetic Resonance Angiography without contrast, abdomen	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8902	Magnetic Resonance Angiography without contrast followed by with contrast, abdomen	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8903	Magnetic Resonance imaging with contrast, breast; unilateral	Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8905	Magnetic Resonance imaging without contrast, breast; unilateral	Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8906	Magnetic Resonance imaging with contrast, breast; bilateral	Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8908	Magnetic Resonance imaging without contrast followed by with contrast, breast; bilateral	Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8909	Magnetic Resonance Angiography with contrast, Chest (excluding myocardium)	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8910	Magnetic Resonance Angiography without contrast, Chest (excluding myocardium)	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8911	Magnetic Resonance Angiography without contrast followed by with contrast, Chest (excluding myocardium)	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8912	Magnetic Resonance Angiography with contrast, lower extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8913	Magnetic Resonance Angiography without contrast, lower extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8914	Magnetic Resonance Angiography without contrast followed by with contrast, lower extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -'Traditional Products do not require preauthorization	Yes	Yes
C8918	Magnetic Resonance Angiography with contrast, pelvis	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8919	Magnetic Resonance Angiography without contrast, pelvis	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8920	Magnetic Resonance Angiography without contrast followed by with contrast, pelvis	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8921	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8922	Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8923	Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, without SPECTRAL or color doppler echocardiography	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8924	Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording when performed, follow-up or limited study	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8925	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without m-mode recording); including probe placement, image acquisition, interpretation and report	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8926	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8927	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for monitoring purposes, including probe placement, real time (2D) image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8928	Transthoracic echocardiography (TTE) 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	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8929	Transthoracic echocardiography (TTE) 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	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8930	Transthoracic echocardiography (TTE) 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	Diagnostic services: Cardiac testing	X-Ray/Imaging - Cardiac studies	This service is preauthorized through Evolent. - Traditional products do not require Preauthorization ASO group contracts do not require Preauthorization 1 applies to fully insured products	Yes	Yes
C8931	Magnetic Resonance Angiography with contrast, spinal canal and contents	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8932	Magnetic resonance angiography without contrast, spinal canal and contents	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8933	Magnetic Resonance Angiography without contrast followed by with contrast, spinal canal and contents	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8934	Magnetic Resonance Angiography with contrast, upper extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8935	Magnetic Resonance Angiography without contrast, upper extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. -Traditional Products do not require preauthorization	Yes	Yes
C8936	Magnetic Resonance Angiography without contrast followed by with contrast, upper extremity	Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
C9069	Injection, belantamab mafodotin-blmf	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. preauthorization only for this specialty injectable	Yes	No
C9070	Injection, tafasitamab-cxix, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9072	Injection immune globulin (asceniv), 500mg	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9073	Brexucabtagene autoleucel, up to 200 million autologous anti-cd 19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose tacaretus	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9171	Injection, fidanacogene eleparvovec-dzkt, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
C9173	Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
C9739	Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants	Investigational and experimental procedures	Investigational bladder procedure		Yes	Yes
C9740	Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants	Investigational and experimental procedures	Investigational bladder procedure		Yes	Yes
C9757	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar	Surgery for select procedures	Nerve Procedures	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
C9763	Cardiac Magnetic Resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging	Diagnostic services: MRI	Diagnostic services : MRI	This service is preauthorized through Evolent. Traditional Products do not require Preauth.	Yes	Yes
D7820	Closed reduction of dislocation; joint manipulated into place; no surgical exposure	Office surgical procedures	Dental procedures	Requires preauthorization only performed in a facility.	Yes	No
D7870	Arthrocentesis; withdrawal of fluid from a joint space by aspiration	Office surgical procedures	Dental procedures	Requires preauthorization only performed in a facility.	Yes	No
D7880	Occlusal orthotic device, by report; presently includes splints provided for treatment of temporomandibular joint dysfunction.	Office surgical procedures	Dental procedures	Requires preauthorization only when performed in a facility.	Yes	No
E0183	Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty	DME: hospital beds & supplies	DME supplies		Yes	No
E0193	Powered air flotation bed (low air Loss therapy )	DME: hospital beds & supplies	Hospital bed		Yes	No
E0194	Air fluidized bed	DME: hospital beds & supplies	Hospital bed		Yes	No
E0250	Hospital bed, fixed height, with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0251	Hospital bed, fixed height, with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0255	Hospital bed, variable height, HI-LO, with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0256	Hospital bed, variable height, HI-LO, with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0260	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0261	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0265	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0266	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0270	Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	Yes
E0277	Powered pressure-reducing air mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0290	Hospital bed, fixed height, without side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0291	Hospital bed, fixed height, without side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0292	Hospital bed, variable height, HI-LO, without side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0293	Hospital bed, variable height, HI-LO, without side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0294	Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0295	Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0296	Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0297	Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0300	Pediatric crib, hospital grade, fully enclosed, with or without top enclosure	DME: hospital beds & supplies	Hospital bed		Yes	Yes
E0301	Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0302	Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, without mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0303	Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0304	Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, with mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0328	Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0329	Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress	DME: hospital beds & supplies	Hospital bed		Yes	No
E0462	Rocking bed, with or without side rails	DME: hospital beds & supplies	Hospital bed		Yes	Yes
E0465	Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)	DME: ventilators & airway assist devices	DME device		Yes	Yes
E0466	Home ventilator, any type, used with Noninvasive interface, (e.g., mask, Chest shell)	DME: ventilators & airway assist devices	DME device		Yes	Yes
E0467	Home ventilator, multi-function Respiratory device, also performs any or all of the additional functions of Oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions	DME: ventilators & airway assist devices	DME device		Yes	Yes
E0468	Home ventilator, dual-function respiratory device, also performs newitional function of cough stimulation, includes all accessories, components and supplies for all functions	DME: ventilators & airway assist devices	DME device		Yes	No
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)	DME: ventilators & airway assist devices	DME: C-PAP & supplies		Yes	Yes
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)	DME: ventilators & airway assist devices	DME: C-PAP & supplies		Yes	Yes
E0472	Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device	DME: ventilators & airway assist devices	DME: C-PAP & supplies		Yes	Yes
E0481	Intrapulmonary percussive ventilation system and related accessories	DME: ventilators & airway assist devices	DME device		Yes	No
E0482	Cough stimulating device, alternating positive and negative airway pressure	DME: ventilators & airway assist devices	DME device		Yes	Yes
E0483	High frequency Chest Wall Oscillation air-pulse generator system, (includes hoses and vest), each	DME: ventilators & airway assist devices	DME device		Yes	Yes
E0486	Oral device/appliance used to reduce upper airway collapsibility, adjustable or Nonadjustable, custom fabricated, includes fitting and adjustment	DME: equipment	DME supplies		Yes	Yes
E0561	Humidifier, Non-heated, used with positive airway pressure device	DME: ventilators & airway assist devices	DME: C-PAP & supplies		Yes	No
E0616	Implantable cardiac event recorder with memory, activator, and programmer	DME: implant	DME device		Yes	Yes
E0617	External defibrillator with integrated electrocardiogram analysis	Defibrillator & supplies	DME supplies		Yes	Yes
E0636	Multi-positional patient support system, with integrated lift, patient accessible controls	DME: patient lifts	DME supplies		Yes	Yes
E0673	Segmental gradient pressure pneumatic appliance, half leg	DME: compression devices	DME supplies		Yes	Yes
E0676	Intermittent limb compression device (includes all accessories), not otherwise specified	DME: compression devices	DME supplies		Yes	No
E0683	Non-pneumatic, non-sequential, peristaltic wave compression pump	DME: compression devices	DME supplies		Yes	No
E0694	Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection	DME: equipment	DME supplies		Yes	Yes
E0737	Transcutaneous tibial nerve stimulator, controlled by phone application	Nerve Stimulators & devices	Nerve Stimulator		Yes	No
E0745	Neuromuscular Stimulator, electronic shock unit	Nerve stimulators and devices	Nerve stimulator		Yes	Yes
E0747	Osteogenesis Stimulator, electrical, Noninvasive, other than spinal applications	Nerve stimulators and devices	Nerve stimulator		Yes	Yes
E0748	Osteogenesis Stimulator, electrical, Noninvasive, spinal applications	Nerve stimulators and devices	Nerve stimulator		Yes	Yes
E0764	Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program	Nerve stimulators and devices	Nerve stimulator		Yes	Yes
E0766	Electrical stimulation device used for cancer treatment, includes all accessories, any type	DME: prosthetic appliances and implants	Nerve stimulator		Yes	Yes
E0782	Infusion pump, implantable, Nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.)	DME: implant	DME pump		Yes	Yes
E0783	Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)	DME: implant	DME pump		Yes	Yes
E0784	External ambulatory infusion pump, insulin	Diabetic DME & supplies	Diabetic Supplies		Yes	Yes
E0785	Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement	DME: implant	DME pump		Yes	Yes
E0786	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)	DME: implant	DME pump		Yes	Yes
E0787	External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing	DME: equipment	DME supplies		Yes	Yes
E0935	Continuous passive motion exercise device for use on knee only	DME: equipment	DME supplies		Yes	Yes
E0951	Heel loop/holder, any type, with or without ankle strap, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0952	Toe loop/holder, any type, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0953	Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0954	Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0955	Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0956	Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0957	Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0958	Manual wheelchair accessory, one-arm drive attachment, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0959	Manual wheelchair accessory, adapter for amputee, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0960	Wheelchair accessory, shoulder harness/straps or Chest strap, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0961	Manual wheelchair accessory, wheel lock brake extension (handle), each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0966	Manual wheelchair accessory, headrest extension, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0967	Manual wheelchair accessory, hand rim with projections, any type, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0968	Commode seat, wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E0969	Narrowing device, wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E0970	No. 2 footplates, except for elevating leg rest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E0971	Manual wheelchair accessory, anti-tipping device, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0973	Wheelchair accessory, adjustable height, Detachable armrest, complete assembly, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0974	Manual wheelchair accessory, anti-rollback device, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0978	Wheelchair accessory, positioning belt/safety belt/pelvic strap, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0980	Safety vest, wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E0981	Wheelchair accessory, seat upholstery, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0982	Wheelchair accessory, back upholstery, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0988	Manual wheelchair accessory, lever-activated, wheel drive, pair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0990	Wheelchair accessory, elevating leg rest, complete assembly, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0992	Manual wheelchair accessory, solid seat insert	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E0994	Armrest, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E0995	Wheelchair accessory, calf rest/pad, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1002	Wheelchair accessory, power seating system, tilt only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1003	Wheelchair accessory, power seating system, recline only, without shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1004	Wheelchair accessory, power seating system, recline only, with mechanical shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1005	Wheelchair accessory, power seating system, recline only, with power shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1006	Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1007	Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1008	Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1009	Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1010	Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1011	Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1012	Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1014	Reclining back, addition to pediatric size wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1016	Shock absorber for power wheelchair, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1017	Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1018	Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1020	Residual limb support system for wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1028	Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1029	Wheelchair accessory, ventilator tray, fixed	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1030	Wheelchair accessory, ventilator tray, gimbaled	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1035	Multi-positional patient transfer system, with integrated seat, operated by care giver, patient Weight capacity up to and including 300 lbs	DME: patient lifts	DME supplies		Yes	Yes
E1036	Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient Weight capacity greater than 300 lbs	DME: patient lifts	DME supplies		Yes	Yes
E1037	Transport chair, pediatric size	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1038	Transport chair, adult size, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1039	Transport chair, adult size, heavy-duty, patient Weight capacity greater than 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1050	Fully reclining wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1060	Fully-reclining wheelchair, Detachable arms, desk or full-length, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1070	Fully-reclining wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1083	Hemi-wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1084	Hemi-wheelchair, Detachable arms desk or full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1085	Hemi-wheelchair, fixed full-length arms, swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1086	Hemi-wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1087	High strength lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1088	High strength lightweight wheelchair, Detachable arms desk or full-length, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1089	High-strength lightweight wheelchair, fixed-length arms, swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1090	High-strength lightweight wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1092	Wide heavy-duty wheel chair, Detachable arms (desk or full-length), swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1093	Wide heavy-duty wheelchair, Detachable arms, desk or full-length arms, swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1100	Semi-reclining wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1110	Semi-reclining wheelchair, Detachable arms (desk or full-length) elevating legrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1130	Standard wheelchair, fixed full-length arms, fixed or swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1140	Wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1150	Wheelchair, Detachable arms, desk or full-length swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1160	Wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1161	Manual adult size wheelchair, includes tilt in space	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1170	Amputee wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1171	Amputee wheelchair, fixed full-length arms, without footrests or legrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1172	Amputee wheelchair, Detachable arms (desk or full-length) without footrests or legrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1180	Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1190	Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1195	Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1200	Amputee wheelchair, fixed full-length arms, swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1220	Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1221	Wheelchair with fixed arm, footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1222	Wheelchair with fixed arm, elevating leg rests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1223	Wheelchair with Detachable arms, footrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1224	Wheelchair with Detachable arms, elevating leg rests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1225	Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1226	Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1227	Special height arms for wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1228	Special back height for wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1229	Wheelchair, pediatric size, not otherwise specified	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1230	Power operated Vehicle (3- or 4-wheel nonhighway), specify brand name and model number	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1231	Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1232	Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1233	Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1234	Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1235	Wheelchair, pediatric size, rigid, adjustable, with seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1236	Wheelchair, pediatric size, folding, adjustable, with seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1237	Wheelchair, pediatric size, rigid, adjustable, without seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1238	Wheelchair, pediatric size, folding, adjustable, without seating system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1239	Power wheelchair, pediatric size, not otherwise specified	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1240	Lightweight wheelchair, Detachable arms, (desk or full-length) swing-away Detachable, elevating legrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1250	Lightweight wheelchair, fixed full-length arms, swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1260	Lightweight wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1270	Lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1280	Heavy-duty wheelchair, Detachable arms (desk or full-length) elevating legrests	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1285	Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1290	Heavy-duty wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1295	Heavy-duty wheelchair, fixed full-length arms, elevating legrest	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E1296	Special wheelchair seat height from floor	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1297	Special wheelchair seat depth, by upholstery	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E1298	Special wheelchair seat depth and/or width, by construction	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2102	Adjunctive, non-implanted continuous glucose monitor or receiver	Diabetic DME and supplies	Diabetic supplies		Yes	No
E2201	Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2202	Manual wheelchair accessory, nonstandard seat frame width, 24-27 in	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2203	Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2204	Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2205	Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2206	Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2208	Wheelchair accessory, cylinder tank carrier, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2209	Accessory, arm trough, with or without hand support, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2210	Wheelchair accessory, bearings, any type, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2211	Manual wheelchair accessory, pneumatic propulsion tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2212	Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2214	Manual wheelchair accessory, pneumatic caster tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2215	Manual wheelchair accessory, tube for pneumatic caster tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2216	Manual wheelchair accessory, foam filled propulsion tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2217	Manual wheelchair accessory, foam filled caster tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2218	Manual wheelchair accessory, foam propulsion tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2219	Manual wheelchair accessory, foam caster tire, any size, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2220	Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2221	Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2222	Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2224	Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2225	Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2226	Manual wheelchair accessory, caster fork, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2227	Manual wheelchair accessory, gear reduction drive wheel, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2228	Manual wheelchair accessory, wheel braking system and lock, complete, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2230	Manual wheelchair accessory, manual standing system	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2231	Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2291	Back, planar, for pediatric size wheelchair including fixed attaching hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2292	Seat, planar, for pediatric size wheelchair including fixed attaching hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2293	Back, contoured, for pediatric size wheelchair including fixed attaching hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2294	Seat, contoured, for pediatric size wheelchair including fixed attaching hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2298	Complex rehabilitative power wheelchair accessory, power seat elevation system, any type	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2310	Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2311	Power wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2312	Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2313	Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2321	Power wheelchair accessory, hand control interface, remote joystick, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2322	Power wheelchair accessory, hand control interface, multiple mechanical switches, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2323	Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2324	Power wheelchair accessory, chin Cup for chin control interface	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2325	Power wheelchair accessory, SIP and PUFF interface, Nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2326	Power wheelchair accessory, breath tube kit for SIP and PUFF interface	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2327	Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2328	Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2329	Power wheelchair accessory, head control interface, contact switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2330	Power wheelchair accessory, head control interface, proximity switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2340	Power wheelchair accessory, nonstandard seat frame width, 20-23 inches	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2341	Power wheelchair accessory, nonstandard seat frame width, 24-27 inches	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2342	Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2343	Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2351	Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2359	Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2361	Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g. gel cell, absorbed glassmat)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2363	Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2365	Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2366	Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2367	Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
E2368	Power wheelchair component, motor, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2369	Power wheelchair component, gear box, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2370	Power wheelchair component, motor and gear box combination, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2371	Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2373	Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2374	Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2375	Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2376	Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2377	Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2378	Power wheelchair component, actuator, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2381	Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2382	Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2383	Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2384	Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2385	Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2386	Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2387	Power wheelchair accessory, foam filled caster tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2388	Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2389	Power wheelchair accessory, foam caster tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2390	Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2391	Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2392	Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2394	Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2395	Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2396	Power wheelchair accessory, caster fork, any size, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2397	Power wheelchair accessory, lithium-based battery, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2398	Wheelchair accessory, dynamic positioning hardware for back	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2402	Negative pressure wound therapy electrical pump, Stationary or Portable	DME: equipment	DME pump		Yes	Yes
E2500	Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time	Investigational and experimental procedures	Speech devices		Yes	Yes
E2502	Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time	Investigational and experimental procedures	Speech devices		Yes	Yes
E2504	Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time	Investigational and experimental procedures	Speech devices		Yes	Yes
E2506	Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time	Investigational and experimental procedures	Speech devices		Yes	Yes
E2508	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device	Investigational and experimental procedures	Speech devices		Yes	Yes
E2510	Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access	Investigational and experimental procedures	Speech devices		Yes	Yes
E2511	Speech generating software program, for personal computer or personal digital assistant	Investigational and experimental procedures	Speech devices		Yes	Yes
E2512	Accessory for speech generating device, mounting system	Investigational and experimental procedures	Speech devices		Yes	Yes
E2513	Accessory For Speech Generatng Device, Electromyographic Sensor	Dme: Speech Generating Devices	Speech devices		Yes	Yes
E2599	Accessory for speech generating device, not otherwise classified	Investigational and experimental procedures	Speech devices		Yes	Yes
E2601	General use wheelchair seat cushion, width less than 22 inches, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2602	General use wheelchair seat cushion, width 22 inches or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2603	Skin protection wheelchair seat cushion, width less than 22 inches, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2604	Skin protection wheelchair seat cushion, width 22 inches or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2605	Positioning wheelchair seat cushion, width less than 22 inches, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2606	Positioning wheelchair seat cushion, width 22 inches or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2607	Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2608	Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2609	Custom fabricated wheelchair seat cushion, any size	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2611	General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2612	General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2613	Positioning wheelchair back cushion, posterior, width less than 22 in, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2614	Positioning wheelchair back cushion, posterior, width 22 in or greater, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2615	Positioning wheelchair back cushion, posterior-lateral, width less than 22 in, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2616	Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2617	Custom fabricated wheelchair back cushion, any size, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2619	Replacement cover for wheelchair seat cushion or back cushion, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2620	Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2621	Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2622	Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2623	Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2624	Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2625	Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2626	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2627	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2628	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2629	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2630	Wheelchair accessory, shoulder elbow, mobile arm support, mono suspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2631	Wheelchair accessory, addition to mobile arm support, elevating proximal arm	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2632	Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E2633	Wheelchair accessory, addition to mobile arm support, supinator	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
E3000	Speech volume modulation system, any type, including all components and accessories	DME: Wheelchairs and accessories	Speech devices		Yes	No
G0151	Services performed by a qualified Physical therapist in the home health or hospice setting, each 15 minutes	Therapy services: Physical therapy	Physical therapy services		Yes	Yes
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes	Therapy services: Occupational therapy	Occupational therapy services		Yes	Yes
G0155	Services of clinical Social worker in home health or hospice settings, each 15 minutes	Other services: Home health care	Home health care		Yes	Yes
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes	Other services: Home health care	Home health care		Yes	Yes
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes	Therapy services: Physical therapy	Physical therapy services		Yes	No
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes	Therapy services: Occupational therapy	Occupational therapy services		Yes	No
G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an rn to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting)	Other services: Home health care	Home health care		No	Yes
G0219	PET imaging whole body; melanoma for non-covered indications	Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
G0235	Pet Imaging, any site, not otherwise specified	Diagnostic services: pet scans	Xray/imaging - pet scan	This service is preauthorized through Evolent. ¬Traditional Products do not require Preauth	Yes	No
G0252	PET imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)	Diagnostic services: PET scans	X-Ray/Imaging - PET scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	Yes
G0299	Direct skilled nursing services of A registered nurse (RN) in the home health or hospice setting, each 15 minutes	Other services: Home health care	Home health care		Yes	Yes
G0300	Direct skilled nursing services of A license practical nurse (LPN) in the home health or hospice setting, each 15 minutes	Other services: Home health care	Home health care		Yes	Yes
G0339	Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G0340	Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G0341	Percutaneous Islet cell Transplant, includes portal vein catheterization and infusion	Transplant surgeries	Organ/Tissue transplant - Islet cell (pancreas)		Yes	No
G0342	Laparoscopy for Islet cell Transplant, includes portal vein catheterization and infusion	Transplant surgeries	Organ/Tissue transplant - Islet cell (pancreas)		Yes	No
G0343	Laparotomy for Islet cell Transplant, includes portal vein catheterization and infusion	Transplant surgeries	Organ/Tissue transplant - Islet cell (pancreas)		Yes	No
G0493	Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)	Home care	Home health care		Yes	Yes
G0494	Skilled services of A licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)	Home care	Home health care		Yes	Yes
G6001	Ultrasonic guidance for placement of Radiation therapy fields	Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6002	Stereoscopic X-RAY guidance for localization of target volume for the delivery of Radiation therapy	Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6003	Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: up to 5MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6004	Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 6-10MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6005	Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 11-19MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6006	Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 20MEV or greater	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6007	Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: up to 5MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6008	Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: 6-10MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6009	Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: 11-19MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
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	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6011	Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; up to 5MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6012	Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 6-10MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6013	Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 11-19MEV	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6014	Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 20MEV or greater	Therapy services: Radiation therapy	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6015	Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session	Therapy services: Radiation therapy , IMRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6016	Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session	Therapy services: Radiation therapy , IMRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
G6017	Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3d positional tracking, gating, 3d surface tracking), each fraction of treatment	Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through Evolent.	Yes	Yes
H0015	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education	Select outpatient behavioral health services	Behavioral health services	Not valid for Medicare purposes.	Yes	No
H0018	Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem	Select outpatient behavioral health services	Behavioral health services		Yes	No
H0035	Mental health partial hospitalization, treatment, less than 24 hours	Select outpatient behavioral health services	Behavioral health services	Not valid for Medicare purposes.	Yes	No
J0129	Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0172	Injection, aducanumab-avwa, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J0174	Injection, lecanemab-irmb, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0175	Injection, donanemab-azbt, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0177	Injection, aflibercept hd, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J0178	Injection, aflibercept, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0638	Injection, canakinumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J0641	Injection, levoleucovorin, not otherwise specified, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J0642	Injection, levoleucovorin (khapzory), 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J2267	Injection, mirikizumab-mrkz, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3263	injection, toripalimab-tpzi, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3393	Injection, betibeglogene autotemcel, per treatment	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3394	Injection lovotibeglogene autotemcel, per treatment	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J2777	Injection, faricimab-svoa, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0179	Injection, brolucizumab-dbll, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0180	Injection, agalsidase beta, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0202	Injection, alemtuzumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0217	Injection, velmanase alfa-tycv, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0218	Injection, olipudase alfa-rpcp, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0219	Injection, avalglucosidase alfa-ngpt, 4 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0221	Injection, alglucosidase alfa, (lumizyme), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0222	Injection, patisiran, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0223	Injection, givosiran, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0224	Injection, lumasiran, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0225	Injection, vutrisiran, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0256	Injection, alpha 1- proteinase inhibitor (human), not otherwise specified, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0257	Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0490	Injection, belimumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0491	Injection, anifrolumab-fnia, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J0517	Injection, benralizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0567	Injection, cerliponase alfa, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0584	Injection, burosumab-twza, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0585	Injection, onabotulinumtoxina, 1 unit	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0586	Injection, abobotulinumtoxina, 5 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0587	Injection, rimabotulinumtoxinB, 100 units	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J0588	Injection, incobotulinumtoxina, 1 unit	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthoirzed by Capital Blue Cross for Commercial.	Yes	No
J0593	Injection, lanadelumab-flyo, 1 mg (code may be used for medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered.	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J0596	Injection, C1 esterase inhibitor (recombinant), rucontest, 10 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0597	Injection, C-1 esterase inhibitor (human), BERINERT, 10 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0598	Injection, C-1 esterase inhibitor (human), CINRYZE, 10 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0717	Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0791	Injection, crizanlizumab-tmca, 5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0870	Injection, imetelstat, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J0881	Injection, darbepoetin alfa, 1 mcg (non-esrd use)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0885	Injection, epoetin alfa, (for non-esrd use), 1000 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0888	Injection, epoetin beta, 1 mcg, (for non-esrd use)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0896	Injection, luspatercept-aamt, 0.25 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J0897	Injection, denosumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1203	Injection, cipaglucosidase alfa-atga , 5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1290	Injection, ecallantide, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	No
J1300	Injection, eculizumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1301	Injection, edaravone, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J1302	INJECTION, SUTIMLIMAB-JOME, 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1303	Injection, ravulizumab-cwvz, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1304	Injection, tofersen, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1305	Injection evkeeza (evinacumab-dgnb), 5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1306	Injection, inclisiran, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J1307	Injection, crovalimab-akkz, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J1322	Injection, elosulfase alfa, 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1323	Injection, elranatamab-bcmm, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1325	Injection, epoprostenol, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J1411	Injection, etranacogene dezaparvove-DRLB, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1412	Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes.	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1413	Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1414	Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1426	Injection, casimersen, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1427	Injection, viltolarsen, 10 mg	Medical injectiables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1428	Injection, eteplirsen, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1429	Injection, golodirsen, 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1437	Injection, ferric derisomaltose, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J1439	Injection, ferric carboxymaltose, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J1442	Injection, filgrastim (G-CSF), excludes biosimilars, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1447	Injection, TBO-filgrastim, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1448	Injection, trilaciclib (cosela) , 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1449	Injection, eflapegrastim-XNST, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1458	Injection, galsulfase, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMedss.	Yes	Yes
J1459	Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1460	Injection, gamma globulin, intramuscular, 1 CC	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J1551	Injection, immune globulin (cutaquig), 100 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for commercial.	Yes	No
J1552	Injection, immune globulin (alyglo), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for commercial.	Yes	No
J1555	Injection, immune globulin (cuvitru), 100 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1556	Injection, immune globulin (bivigam), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1557	Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1558	Injection, immune globulin (xembify), 100 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1559	Injection, immune globulin (hizentra), 100 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1560	Injection, gamma globulin, intramuscular, over 10 cc	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	No
J1561	Injection, immune globulin, (gamunex- c/gammaked), non-lyophilized (E. G. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1566	Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1568	Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1569	Injection, immune globulin, (gammagard liquid), non-lyophilized, (E. G. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1572	Injection, immune globulin, (flebogamma/flebogamma Dif), intravenous, non-lyophilized (e.g. liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1575	Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immunoglobulin	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1576	Injection, immune globulin (panzyga), intravenous,non-lyophilized (e.g., liquid), 500 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J1599 (Yimmugo)	Yimmugo NDC 83372-0605-XX	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1602	Injection, golimumab, 1 mg, for intravenous use	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1628	Injection, guselkumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J1743	Injection, idursulfase, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1745	Injection, infliximab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J1786	Injection, imiglucerase, 10 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1823	Injection, inebilizumab-cdon, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1931	Injection, laronidase, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J2182	Injection, mepolizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2323	Injection, natalizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2326	Injection, nusinersen, 0.1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg (skyrizi)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J2329	Injection, ublituximab-xiiy, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J2350	Injection, ocrelizumab, 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2357	Injection, omalizumab, 5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2506	Injection, pegfilgrastim, excludes biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J2507	Injection, pegloticase, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2508	Injection, pegunigalsidase alfa-iwxj, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J2778	Injection, ranibizumab, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2786	Injection, reslizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2793	Injection, rilonacept, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J2802	Injection, romiplostim, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J2820	Injection, sargramostim (GM-CSF), 50 mcg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2840	Injection, sebelipase alfa, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J2998	Injection, plasminogen, human-tvmh, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3032	Injection, eptinezumab-jjmr, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J3055	Injection, talquetamab-tgvs, 0.25 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J3060	Injection, taliglucerase alfa, 10 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3111	Injection, romosozumab-aqqg, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	"This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3241	Injection, teprotumumab-trbw, 10 mg	Medical injectables/other non-injectable drugs	Injection procedure	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3245	Injection, tildrakizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3262	Injection, tocilizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3285	Injection, treprostinil, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3357	Ustekinumab, for subcutaneous Injection, 1 mg Injection	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
J3358	Ustekinumab for intravenous injection, 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3380	Injection, vedolizumab, intravenous 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3385	Injection, velaglucerase alfa, 100 units	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3392	Injection, exagamglogene autotemcel, per treatment	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3397	Injection, vestronidase alfa-vjbk, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3398	Injection, voretigene neparvovec-rzyl, 1 billion vector genomes	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3399	Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5X10^15 vector genomes	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J3401	Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector geomes, per 0.1ml	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J3490 (Rivfloza)	rivfloza (nedosiran) ndc 0169-5308-01 ndc 0169-5307-08 ndc 0169-5306-10	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3490 (Tegsedi)	Injection, tegsedi (inotersen) 1.5 ml in 1 syringe NDC 72126-007-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Ahzantive)	Ahzantive (Aflibercept-Mrbb) Ndc Tbd	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Entyvio SQ)	Entyvio, subcutaneous (vedolizumab) ndc 64764-0107-11 ndc 64764-0108-21	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Enspryng)	Enspryng (satralizumab) - NDC 50242-007-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Enzeevu)	Enzeevu (aflibercept-abzv) ndc 61314-504-63; 61314-504-94	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Epysqli)	Epysqli (Eculizumab-Aagh) Ndc 71202-010-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (LANTIDRA)	Lantidra (Donislecel-jujn) NDC 73539-001-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Lenmeldy)	Lenmeldy (ATIDARSAGENE AUTOTEMCEL) NDC 83222-0200-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Niktimvo)	Niktimvo (Axatilimab-Csfr) Ndc: 50881-012-10	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Ocrevus Zunovo)	Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) ndc 50242-554-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (OMISIRGE)	Omisrge (Idubicel-onlv NDC 73441-800-04)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Opuviz)	Opuviz (aflibercept-yszy) ndc 64406-028-01; 64406-028-03	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Pavblu)	Pavblu (aflibercept- ayyh) ndc 55513-056-01; 55513-065-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Skysona)	Skysona (elivaldogene autotemcel) NDC - 73554-2111-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Tyenne SQ)	Tyenne Sq (Tocilizumab-Aazg) Ndc 65219-586-04; 65219-584-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Winrevair)	WINREVAIR (SOTATERCEPT-SCRK) NDC 00006-5090-01; 00006-5087-01; 00006-5091-01; 00006-5088-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J3590 (Yesafili)	Yesafili (aflibercept-jbvf) ndc 83257-013-11	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J9999 (Avzivi)	Avzivi (bevacizumab-tnjn) NDC: 82143-001-01 NDC: 82143-002-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J9999 (Amtagvi)	amtagvi (lifileucel) ndc 73776-001-11ndc 73776-001-12	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J9999 (Lymphir)	Lymphir (Denileukin Difitox-Cxdl) Ndc: 52658-7777-1	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J9999 (Tecelra)	Tecelra (Afamitresgene Autoleucel) Ndc: 83205-0001-2	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J9999 (Tecentriq Hybreza)	Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) ndc 50242-933-01	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.	Yes	No
J7179	Injection, von willebrand factor (recombinant), (vonvendi), 1 iu vwf:rco	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7170	Injection, emicizumab-kxwh, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7171	Injection, adamts13, recombinant-krhn, 10 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7175	Injection, factor x, (human), 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7180	Injection, factor xiii (antihemophilic factor, human), 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7181	Injection, factor xiii a-subunit, (recombinant), per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7182	Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7183	Injection, von willebrand factor complex (human), wilate, 1 iu vwf:rco	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7185	Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7187	injection, von willebrand factor complex (humate-p), per iu vwf:rco	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7186	Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7188	Injection, factor viii (antihemophilic factor, recombinant) (obizur), per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7189	Factor VIIA (Antihemophilic, Recombinant), (Novoseven rt), 1MCG	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7190	Factor viii (antihemophilic factor, human) per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7192	Factor viii (antihemophilic factor, recombinant) per iu, not otherwise specified	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7193	Factor ix (antihemophilic factor, purified, nonrecombinant) per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7194	factor ix complex, per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7195	Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified	Medical injectables/ other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7194	Factor IX, Complex, per I.U.	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7198	Antiinhibitor, per I.U.	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7200	Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7201	Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7202	Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7203	Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7204	Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7205	Injection, factor viii fc fusion protein (recombinant), per iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7207	Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 iu	Medical injectables/ other non-injectable drugs.	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7208	Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi) 1 iu	Medical injectables/ other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7209	Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7210	Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 iu	Medical injectables/ other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7211	Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7212	Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 mcg	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7213	Injection, coagulation factor ix (recombinant), ixinity, 1 iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7214	Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii iu	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J7318	Hyaluronan or derivative, durolane, for intra- articular injection, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7320	Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7321	Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7322	Hyaluronan or derivative, hymovis, for intra- articular injection, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMedss.	Yes	Yes
J7324	Hyaluronan or derivative, orthovisc, for intra- articular injection, per dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7326	Hyaluronan or derivative, gel-one, for intra- articular injection, per dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7327	Hyaluronan or derivative, monovisc, for intra- articular injection, per dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7328	Hyaluronan or derivative, gel-syn, for intra- articular injection, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7329	Hyaluronan or derivative, trivisc, for intra- articular injection, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7330	Autologous cultured chondrocytes, implant	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
J7331	Hyaluronan or derivative, SYNOJOYNT, for intra-articular injection, 1 mg SYNOJOYNT and 1% sodium hyaluronate (J code for both drugs different NDC)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7332	Hyaluronan or derivative, TRILURON, for intra- articular injection, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J7352	Afamelanotide implant, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9015	Injection, aldesleukin, per single use vial	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J9021	Injection, asparaginase, recombinant, (rylaze), 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9022	Injection, atezolizumab, 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9023	Injection, avelumab, 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9026	Injection, tarlatamab, dlle, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9028	Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9033	Injection, bendamustine hydrochloride, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9034	Injection, Bendamustine Hcl (Bendeka), 1mg	Medical Injectables/Other Non-Injectable Drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service.	Yes	No
J9035	Injection, bevacizumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9036	Injection, Bendamustine Hcl (Belrapzo/Bendamustine), 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	No
J9037	Injection, belantamab mafodotin-blmf, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9039	Injection, blinatumomab, 1 mcg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9042	Injection, brentuximab vedotin, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9043	Injection, cabazitaxel, 1 mg (Jevtana)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9047	Injection carfilzomib 1 mg (kyprolis)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9055	Injection, cetuximab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9056	Injection, Bendamustine Hcl (Vivimusta), 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9058	Injection, Bendamustine Hcl (Apotex), 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9059	Injection, Bendamustine Hcl (Baxter), 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9061	Injection, amivantamab-vmjw, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9063	Injection, mirvetuximab soravtansine-gynx, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9064	Cabazitaxel (SANDOZ), not Therapeutically equivalent to J9043, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J9119	Injection, Cemiplimab-Rwlc, 1 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9144	Injection, daratumumab, 10mg and hyaluronidase-fihj	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation.	Yes	No
J9145	Injection, daratumumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9173	Injection, durvalumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9176	Injection, elotuzumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9203	Injection, gemtuzumab ozogamicin, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9210	Injection, emapalumab-lzsg, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J9204	Injection, mogamulizumab-kpkc, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9223	Injection, lurbinectedin, 0.1 mg (zepzelka)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9228	Injection, ipilimumab (yervoy), 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9247	Injection, melphalan flufenamide hcl, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9264	Injection, paclitaxel protein-bound particles, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9271	Injection, pembrolizumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9272	Injection, dostarlimab-gxly, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9273	Injection, tisotumab vedotin-tftv, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9274	Injection, tebentafusp-tebn, 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9281	Mitomycin pyelocalyceal instillation, 1 mg	Medical injectables/other non-injectable drugs	Injection procedure	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9286	Injection, glofitamab-gxbm, 2.5 mg	Medical injectables/other non-injectable drugs	Injection procedure	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9299	Injection, nivolumab, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9301	Injection, obinutuzumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9302	Injection, ofatumumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9303	Injection, panitumumab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9305	Pemetrexed (alimta)	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9306	Injection, Pertuzumab, 1 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9308	Injection, ramucirumab, 5mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9309	Injection, polatuzumab vedotin-piiq, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9311	Injection, rituximab 10 mg and hyaluronidase	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9312	Injection, rituximab, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9316	Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9317	Injection, sacituzumab govitecan-hziy, 2.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
J9318	Injection, romidepsin, nonlyophilized, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9319	Injection, romidepsin, lyophilized, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This services is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9321	Injection, epcoritamab-bysp, 0.16mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9329	Injection, Tislelizumab-Jsgr, 1 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
J9331	Injection, sirolimus protein-bound particles, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9332	Injection, efgartigimod alfa-fcab, 2mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthoirzed by Capital Blue Cross for Commercial.	Yes	No
J9333	Injection, rozanolixizumab-noli, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthoirzed by Capital Blue Cross for Commercial.	Yes	No
J9334	Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthoirzed by Capital Blue Cross for Commercial.	Yes	No
J9345	Injection, Retifanlimab-dlwr, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
J9347	Injection, tremelimumab-actl, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9348	Injection, naxitamab-gqgk, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9349	Injection, tafasitamab-cxix, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9354	Injection Ado-trastuzumab emtansine	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9355	Injection, Trastuzumab, excludes biosimilar, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9356	Injection, Trastuzumab, 10 mg and hyaluronidase-OYSK	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9358	Injection, fam-trastuzumab deruxtecan-nxki, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9359	Injection, loncastuximab tesirine-lpyl, 0.075 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9361	Injection, efbemalenograstim alfa-vuxw, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for commercial.	Yes	No
J9376	Injection, pozelimab-bbfg, 1mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for commercial.	Yes	No
J9380	Injection, teclistamab-cqyv, 0.5mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9381	Injection, teplizumab-mzwv, 5mcg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
J9400	Injection, ZIV-aflibercept, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
K0002	Standard HEMI (low seat) wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0004	High strength, lightweight wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0005	Ultralightweight wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0006	Heavy-duty wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0007	Extra heavy-duty wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0008	Custom manual wheelchair/base	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0009	Other manual wheelchair/base	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0010	Standard-Weight frame motorized/power wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0011	Standard-Weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0012	Lightweight Portable motorized/power wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0013	Custom motorized/power wheelchair base	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0014	Other motorized/power wheelchair base	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0015	Detachable, Nonadjustable height armrest, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0017	Detachable, adjustable height armrest, base, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0018	Detachable, adjustable height armrest, upper portion, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0019	Arm pad, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0020	Fixed , adjustable height armrest, pair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0037	High mount flip-up footrest, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0038	Leg strap, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0039	Leg strap, H STYLE, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0040	Adjustable angle footplate, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0041	Large size footplate, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0042	Standard size footplate, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0043	Footrest, lower extension tube, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0044	Footrest, upper hanger bracket, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0045	Footrest, complete assembly	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0046	Elevating leg rest, lower extension tube, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0047	Elevating leg rest, upper hanger bracket, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0050	Ratchet assembly	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0051	Cam release assembly, footrest or leg rest, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0052	Swingway, Detachable footrests, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0056	Seat height less than 17 in or equal to or greater than 21 in for A high-strength, lightweight, or Ultra lightweight wheelchair	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0065	Spoke protectors, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0069	Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0070	Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0071	Front caster assembly, complete, with pneumatic tire, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0072	Front caster assembly, complete, with semi-pneumatic tire, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0073	Caster Pin lock, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0077	Front caster assembly, complete, with solid tire, replacement only, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0098	Drive belt for power wheelchair, replacement only	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0105	IV hanger, each	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0195	Elevating legrests, pair (for use with capped rental wheelchair base)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0462	Temporary replacement for patient-owned equipment being repaired, any type	DME: equipment	DME Rental		Yes	Yes
K0606	Automatic external defibrillator, with integrated electrocardiogram analysis, garment type	Defibrillator & supplies	DME supplies		Yes	No
K0669	Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
K0733	Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0739	Repair or non routine service for durable Medical equipment other than Oxygen equipment requiring the skill of a technician, labor component, per 15 minutes	DME: equipment	DME Repair		Yes	Yes
K0744	Absorptive wound dressing for use with suction pump, home model, Portable, pad size 16 SQ in or less	No category on the Professional COC - only facility	Wound care		Yes	No
K0745	Absorptive wound dressing for use with suction pump, home model, Portable, pad size more than 16 SQ in but less than or equal to 48 SQ in	No category on the Professional COC - only facility	Wound care		Yes	No
K0746	Absorptive wound dressing for use with suction pump, home model, Portable, pad size, greater than 48 SQ in	No category on the Professional COC - only facility	Wound care		Yes	No
K0800	Power operated Vehicle, group 1 standard, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0801	Power operated Vehicle, group 1 heavy-duty, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0802	Power operated Vehicle, group 1 very heavy-duty, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0812	Power operated Vehicle, not otherwise classified	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0813	Power wheelchair, group 1 standard, Portable, sling/solid seat and back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0814	Power wheelchair, group 1 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0815	Power wheelchair, group 1 standard, sling/solid seat and back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0816	Power wheelchair, group 1 standard, captains chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0820	Power wheelchair, group 2 standard, Portable, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0821	Power wheelchair, group 2 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0822	Power wheelchair, group 2 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0823	Power wheelchair, group 2 standard, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0824	Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0825	Power wheelchair, group 2 heavy-duty, captain's chair, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0826	Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0827	Power wheelchair, group 2 very heavy duty, captains chair, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0828	Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0829	Power wheelchair, group 2 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0830	Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
K0831	Power wheelchair, group 2 standard, seat elevator, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	No
K0835	Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0836	Power wheelchair, group 2 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0837	Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0838	Power wheelchair, group 2 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0839	Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0840	Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0841	Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0842	Power wheelchair, group 2 standard, multiple power option, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0843	Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0848	Power wheelchair, group 3 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0849	Power wheelchair, group 3 standard, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0850	Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0851	Power wheelchair, group 3 heavy duty, captains chair, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0852	Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0853	Power wheelchair, group 3 very heavy duty, captains chair, patient Weight capacity, 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0854	Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0855	Power wheelchair, group 3 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0856	Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0857	Power wheelchair, group 3 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0858	Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient Weight 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0859	Power wheelchair, group 3 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0860	Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0861	Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0862	Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0863	Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0864	Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 601 pounds or more	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0890	Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0891	Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0898	Power wheelchair, not otherwise classified	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0899	Power mobility device, not coded by DME PDAC or does not meet criteria	DME: Wheelchairs and accessories	Wheelchairs and accessories		Yes	Yes
K0900	Customized durable Medical equipment, other than wheelchair	DME: equipment	DME Rental		Yes	Yes
K1001	Electronic positional OBSTRUCTIVE SLEEP APNEA treatment, with sensor, includes all components and accessories, any type	DME: ventilators & airway assist devices	DME: C-PAP & supplies DME device		Yes	Yes
K1027	Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment	DME: C-PAP and supplies	DME device		Yes	Yes
L0452	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated	DME: spinal orthotics	Orthotics		Yes	Yes
L0480	TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal	DME: spinal orthotics	Orthotics		Yes	Yes
L0482	TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch	DME: spinal orthotics	Orthotics		Yes	Yes
L0484	TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal	DME: spinal orthotics	Orthotics		Yes	Yes
L0486	TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch	DME: spinal orthotics	Orthotics		Yes	Yes
L0622	Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	DME: spinal orthotics	Orthotics		Yes	Yes
L0624	Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	DME: spinal orthotics	Orthotics		Yes	Yes
L0629	Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, SHOU	DME: spinal orthotics	Orthotics		Yes	Yes
L0632	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may	DME: spinal orthotics	Orthotics		Yes	Yes
L0634	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce LOA	DME: spinal orthotics	Orthotics		Yes	Yes
L0636	Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid latera	DME: spinal orthotics	Orthotics		Yes	Yes
L0638	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to R	DME: spinal orthotics	Orthotics		Yes	Yes
L0640	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to XYPHOID, produces intracavitary pressure to reduce load on the intervertebral	DME: spinal orthotics	Orthotics		Yes	Yes
L1834	Knee orthotic (KO), without knee joint, rigid, custom fabricated	Knee orthotics	Orthotics		Yes	No
L1840	Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated	Knee orthotics	Orthotics		Yes	No
L1844	Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	Knee orthotics	Orthotics		Yes	No
L1846	Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	Knee orthotics	Orthotics		Yes	No
L1900	Ankle foot orthosis, spring wire, dorsiflexion assist calf Band, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1904	Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1907	Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1920	Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1940	Ankle foot orthosis, plastic or other material , custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1945	Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1950	Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1960	Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1970	Ankle foot orthosis, plastic with ankle joint, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1980	Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (single BAR 'BK' orthosis), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L1990	Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (double bar 'BK' orthosis), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2000	Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2005	Knee ankle foot orthosis, any material, single or double upright, stance control, Automatic lock and Swing phase release, any type activation, includes ankle joint, any type, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2006	Knee ankle foot device, any material, single or double upright, Swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), Custom F	DME: ankle, foot and knee orthotics	DME device		Yes	Yes
L2010	Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), without knee joint, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2020	Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthosis), custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2030	Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthosis), without knee joint, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2034	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2036	Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2037	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2038	Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2106	Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material , custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2108	Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2126	Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material , custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L2128	Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L4205	Repair of orthotic device, labor component, per 15 minutes	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L4210	Repair of orthotic device, repair or replace minor parts	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L4631	Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material , includes straps and closures, custom fabricated	DME: ankle, foot and knee orthotics	Orthotics		Yes	Yes
L5000	Partial foot, shoe insert with longitudinal arch, toe filler	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5010	Partial foot, molded socket, ankle height, with toe filler	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5020	Partial foot, molded socket, tibial tubercle height, with toe filler	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5050	Ankle, symes, molded socket, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5060	Ankle, symes, metal frame, molded leather socket, articulated ankle/foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5100	Below knee, molded socket, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5105	Below knee, plastic socket, joints and thigh lacer, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5150	Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5160	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5200	Above knee, molded socket, single axis constant friction knee, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5210	Above knee, short prosthesis, No knee joint ('stubbies'), with foot blocks, No ankle joints, each	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5220	Above knee, short prosthesis, No knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5230	Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5250	Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5270	Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5280	Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5301	Below knee, molded socket, shin, sach foot, endoskeletal system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5312	Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5321	Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5331	Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5341	Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5500	Initial, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5505	Initial, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5510	Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5520	Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5530	Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5535	Preparatory, below knee 'PTB' type socket, Non-alignable system, No cover, sach foot, prefabricated, adjustable open end socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5540	Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, laminated socket, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5560	Preparatory, above knee- knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5570	Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5580	Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5585	Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, prefabricated adjustable open end socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5590	Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon no cover, sach foot, laminated socket, molded to model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5595	Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, thermoplastic or equal, molded to patient model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5600	Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, laminated socket, molded to patient model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5610	Addition to lower extremity, endoskeletal system, above knee, hydracadence system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5611	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5613	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5614	Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5615	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxal, fluid swing and stance phase control.	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5616	Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5617	Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5618	Addition to lower extremity, test socket, symes	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5620	Addition to lower extremity, test socket, below knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5622	Addition to lower extremity, test socket, knee disarticulation	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5624	Addition to lower extremity, test socket, above knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5626	Addition to lower extremity, test socket, hip disarticulation	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5628	Addition to lower extremity, test socket, hemipelvectomy	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5629	Addition to lower extremity, below knee, acrylic socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5630	Addition to lower extremity, symes type, expandable wall socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5631	Addition to lower extremity, above knee or knee disarticulation, acrylic socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5632	Addition to lower extremity, symes type, 'PTB' brim design socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5634	Addition to lower extremity, symes type, posterior opening (Canadian) socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5636	Addition to lower extremity, symes type, medial opening socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5637	Addition to lower extremity, below knee, total contact	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5638	Addition to lower extremity, below knee, leather socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5639	Addition to lower extremity, below knee, wood socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5640	Addition to lower extremity, knee disarticulation, leather socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5642	Addition to lower extremity, above knee, leather socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5643	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5644	Addition to lower extremity, above knee, wood socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5645	Addition to lower extremity, below knee, flexible inner socket, external frame	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5646	Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5647	Addition to lower extremity, below knee suction socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5648	Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5649	Addition to lower extremity, ischial containment/narrow M-L socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5650	Additions to lower extremity, total contact, above knee or knee disarticulation socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5651	Addition to lower extremity, above knee, flexible inner socket, external frame	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5652	Addition to lower extremity, suction suspension, above knee or knee disarticulation socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5653	Addition to lower extremity, knee disarticulation, expandable wall socket	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5654	Addition to lower extremity, socket insert, symes, (kemlo, pelite, aliplast, plastazote or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5655	Addition to lower extremity, socket insert, below knee (kemlo, pelite, aliplast, plastazote or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5656	Addition to lower extremity, socket insert, knee disarticulation (kemlo, pelite, aliplast, plastazote or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5658	Addition to lower extremity, socket insert, above knee (kemlo, pelite, aliplast, plastazote or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5661	Addition to lower extremity, socket insert, multi-durometer symes	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5665	Addition to lower extremity, socket insert, multi-durometer, below knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5666	Addition to lower extremity, below knee, cuff suspension	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5668	Addition to lower extremity, below knee, molded distal cushion	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5670	Addition to lower extremity, below knee, molded supracondylar suspension ('PTS' or similar)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5671	Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5672	Addition to lower extremity, below knee, removable medial brim suspension	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5673	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5676	Additions to lower extremity, below knee, knee joints, single axis, pair	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5677	Additions to lower extremity, below knee, knee joints, polycentric, pair	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5678	Additions to lower extremity, below knee, joint covers, pair	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5679	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5680	Addition to lower extremity, below knee, thigh lacer, non-molded	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5681	Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5682	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5683	Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5684	Addition to lower extremity, below knee, fork strap	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5685	Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5686	Addition to lower extremity, below knee, back check (extension control)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5688	Addition to lower extremity, below knee, waist belt, webbing	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5690	Addition to lower extremity, below knee, waist belt, padded and lined	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5692	Addition to lower extremity, above knee, pelvic control belt, light	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5694	Addition to lower extremity, above knee, pelvic control belt, padded and lined	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5695	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene equal, each	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5696	Addition to lower extremity, above knee or knee disarticulation, pelvic joint	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5697	Addition to lower extremity, above knee or knee disarticulation, pelvic Band	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5698	Addition to lower extremity, above knee or knee disarticulation, silesian bandage	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5699	All lower extremity prostheses, shoulder harness	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5700	Replacement, socket, below knee, molded to patient model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5701	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5702	Replacement, socket, hip disarticulation, including hip joint, molded to patient model	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5703	Ankle, symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5704	Custom shaped protective cover, below knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5705	Custom shaped protective cover, above knee	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5706	Custom shaped protective cover, knee disarticulation	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5707	Custom shaped protective cover, hip disarticulation	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5710	Addition, exoskeletal knee-shin system, single axis, manual lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5711	Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light-material	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5712	Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5714	Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5716	Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5718	Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5722	Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5724	Addition, exoskeletal knee-shin system, single axis, fluid swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5726	Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5728	Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5780	Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5781	Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5782	Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5785	Addition, exoskeletal system, below knee, ultra-light-material (titanium, carbon fiber or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5790	Addition, exoskeletal system, above knee, ultra-light-material (titanium, carbon fiber or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5795	Addition, exoskeletal system, hip disarticulation, ultra-light-material (titanium, carbon fiber or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5810	Addition, endoskeletal, knee-shin system, single axis, manual lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5811	Addition, endoskeletal, knee-shin system, single axis, manual lock, ultra-light-material	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5812	Addition, endoskeletal, knee-shin system, single axis, friction swing and stance phase control (safety knee)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5814	Addition, endoskeletal, knee-shin system, polycentric, hydraulic swing phase control , mechanical stance phase lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5816	Addition, endoskeletal, knee-shin system, polycentric, mechanical stance phase lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5818	Addition, endoskeletal, knee-shin system, polycentric, friction swing, and stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5822	Addition, endoskeletal, knee-shin system, single axis, pneumatic swing, friction stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5824	Addition, endoskeletal, knee-shin system, single axis, fluid swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5826	Addition, endoskeletal, knee-shin system, single axis, hydraulic swing phase control , with miniature high activity frame	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5828	Addition, endoskeletal, knee-shin system, single axis, fluid swing and stance phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5830	Addition, endoskeletal, knee-shin system, single axis, pneumatic/ Swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5840	Addition, endoskeletal knee/shin system, 4-BAR linkage or multiaxial, pneumatic swing phase control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5845	Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5848	Addition to endoskeletal knee-shin system, FLUID stance extension, dampening feature, with or without adjustability	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5850	Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5855	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing and stance phase, includes electronic sensor(s), any type	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5857	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing phase only, includes electronic sensor(s), any type	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5858	Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5910	Addition, endoskeletal system, below knee, alignable system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5920	Addition, endoskeletal system, above knee or hip disarticulation, alignable system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5925	Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5926	Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5930	Addition, endoskeletal system, high activity knee control frame	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5940	Addition, endoskeletal system, below knee, ultra-light-material (titanium, carbon fiber or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5950	Addition, endoskeletal system, above knee, ultralight material (titanium, carbon fiber or equal) -	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5960	Addition, endoskeletal system, hip disarticulation, ultra-light-material (titanium, carbon fiber or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5961	Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5962	Addition, endoskeletal system, below knee, flexible protective outer surface covering system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5964	Addition, endoskeletal system, above knee, flexible protective outer surface covering system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5966	Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5968	Addition to lower limb prothesis, multiaxial ankle with Swing phase active dorsiflexion feature	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5970	All lower extremity prostheses, foot, external keel, sach foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5971	All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5972	All lower extremity prostheses, foot, flexible keel	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5974	All lower extremity prostheses, foot, single axis ankle/foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5975	All lower extremity prosthesis, combination single axis ankle and flexible keel foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5976	All lower extremity prostheses, energy Storing foot (seattle carbon copy II or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5978	All lower extremity prostheses, foot, multiaxial ankle/foot	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5979	All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5980	All lower extremity prostheses, flex foot system	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5981	All lower extremity prostheses, flex-walk system or equal	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5982	All exoskeletal lower extremity prostheses, axial rotation unit	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5984	All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5985	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5986	All lower extremity prostheses, multi-axial rotation unit ('MCP' or equal)	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5987	All lower extremity prosthesis, shank foot system with vertical loading pylon	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5988	Addition to lower limb prothesis, vertical shock reducing pylon feature	Lower extremity: Prosthetics	Prosthetics		Yes	Yes
L5990	Addition to lower extremity prosthesis, user adjustable heel height	Lower extremity: Prosthetics	Prosthetics		Yes	No
L5991	Addition to lower extremity prosthesis, Osseointegrated External Prosthetic Connector	Lower extremity: Prosthetics	Prosthetics		Yes	No
L6000	Partial hand, thumb remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6010	Partial hand, little and/or ring finger remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6020	Partial hand, No finger remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6050	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6055	Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6100	Below elbow, molded socket, flexible elbow hinge, triceps pad	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6110	Below elbow, molded socket, (muenster or northwestern suspension types)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6120	Below elbow, molded double wall split socket, STEP-up hinges, half cuff	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6130	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6200	Elbow disarticulation, molded socket, outside locking hinge, forearm	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6205	Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6250	Above elbow, molded double wall socket, internal locking elbow, forearm	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6300	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6310	Shoulder disarticulation, passive restoration (complete prosthesis)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6320	Shoulder disarticulation, passive restoration (shoulder CAP only)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6350	Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6360	Interscapular thoracic, passive restoration (complete prosthesis)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6370	Interscapular thoracic, passive restoration (shoulder CAP only)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6400	Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6450	Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6500	Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6550	Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6570	Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6580	Preparatory, wrist disarticulation or below elbow, single Wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, molded to patient model	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6582	Preparatory, wrist disarticulation or below elbow, single Wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, direct formed	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6584	Preparatory, elbow disarticulation or above elbow, single Wall plastic socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6586	Preparatory, elbow disarticulation or above elbow, single Wall socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, direct formed	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6588	Preparatory, shoulder disarticulation or interscapular thoracic, single Wall plastic socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6590	Preparatory, shoulder disarticulation or interscapular thoracic, single Wall socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, direct formed	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6600	Upper extremity additions, polycentric hinge, pair	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6605	Upper extremity additions, single pivot hinge, pair	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6610	Upper extremity additions, flexible metal hinge, pair	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6611	Addition to upper extremity prosthesis, external powered, additional switch, any type	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6615	Upper extremity addition, disconnect locking wrist unit	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6616	Upper extremity addition, additional disconnect insert for locking wrist unit, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6620	Upper extremity addition, flexion/extension wrist unit, with or without friction	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6621	Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6623	Upper extremity addition, spring assisted rotational wrist unit with latch release	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6624	Upper extremity addition, flexion/extension and rotation wrist unit	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6625	Upper extremity addition, rotation wrist unit with cable lock	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6628	Upper extremity addition, QUICK disconnect hook adapter, otto bock or equal	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6629	Upper extremity addition, QUICK disconnect lamination collar with coupling piece, otto bock or equal	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6630	Upper extremity addition, stainless steel, any wrist	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6632	Upper extremity addition, latex suspension sleeve, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6635	Upper extremity addition, lift assist for elbow	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6637	Upper extremity addition, nudge control elbow lock	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6638	Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6640	Upper extremity additions, shoulder abduction joint, pair	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6641	Upper extremity addition, excursion amplifier, pulley type	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6642	Upper extremity addition, excursion amplifier, lever type	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6645	Upper extremity addition, shoulder flexion-abduction joint, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6646	Upper extremity addition, shoulder joint, multi-positional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6647	Upper extremity addition, shoulder lock mechanism, body powered actuator	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6648	Upper extremity addition, shoulder lock mechanism, external powered actuator	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6650	Upper extremity addition, shoulder universal joint, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6655	Upper extremity addition, standard control cable, extra	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6660	Upper extremity addition, heavy duty control cable	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6665	Upper extremity addition, teflon, or equal, cable lining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6670	Upper extremity addition, hook to hand, cable adapter	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6672	Upper extremity addition, harness, Chest or shoulder, SADDLE type	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6675	Upper extremity addition, harness, (e.g., figure of eight type), single cable design	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6676	Upper extremity addition, harness, (e.g., figure of eight type), dual cable design	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6680	Upper extremity addition, test socket, wrist disarticulation or below elbow	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6682	Upper extremity addition, test socket, elbow disarticulation or above elbow	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6684	Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6686	Upper extremity addition, suction socket	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6687	Upper extremity addition, frame type socket, below elbow or wrist disarticulation	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6688	Upper extremity addition, frame type socket, above elbow or elbow disarticulation	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6689	Upper extremity addition, frame type socket, shoulder disarticulation	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6690	Upper extremity addition, frame type socket, interscapular-thoracic	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6691	Upper extremity addition, removable insert, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6692	Upper extremity addition, silicone gel insert or equal, each	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6693	Upper extremity addition, locking elbow, forearm counterbalance	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6694	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6695	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6696	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6697	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for Othe	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6698	Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6703	Terminal device, passive hand/MITT, any material, any size	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6704	Terminal device, Sport/recreational/work attachment, any material, any size	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6706	Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6707	Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6708	Terminal device, hand, mechanical, voluntary opening, any material, any size	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6709	Terminal device, hand, mechanical, voluntary closing, any material, any size	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6711	Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6712	Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6713	Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6714	Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6721	Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6722	Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6805	Addition to terminal device, modifier wrist unit	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6810	Addition to terminal device, precision pinch device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6881	Automatic grasp feature, addition to upper limb electric prosthetic terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6882	Microprocessor control feature, addition to upper limb prosthetic terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6883	Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6884	Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6885	Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6890	Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6895	Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6900	Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6905	Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6910	Hand restoration (casts, shading and measurements included), partial hand, with glove, No fingers remaining	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6915	Hand restoration (shading, and measurements included), replacement glove for above	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6920	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6925	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6930	Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6935	Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6940	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6945	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6950	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6955	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6960	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6965	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6970	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L6975	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal D	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7007	Electric hand, switch or myoelectric controlled, adult	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7008	Electric hand, switch or myoelectric, controlled, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7009	Electric hook, switch or myoelectric controlled, adult	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7040	Prehensile actuator, switch controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7045	Electric hook, switch or myoelectric controlled, pediatric	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7170	Electronic elbow, hosmer or equal, switch controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7180	Electronic elbow, microprocessor sequential control of elbow and terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7181	Electronic elbow, microprocessor Simultaneous control of elbow and terminal device	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7185	Electronic elbow, adolescent, variety village or equal, switch controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7186	Electronic elbow, child, variety village or equal, switch controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7190	Electronic elbow, adolescent, variety village or equal, myoelectric-controlled controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7191	Electronic elbow, child, variety village or equal, myoelectric-controlled controlled	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7259	Electronic wrist rotator, any type	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7400	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7401	Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7402	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7403	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7404	Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7405	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material	Upper extremity prosthetics	Prosthetics		Yes	Yes
L7510	Repair of prosthetic device, repair or replace minor parts	DME: prosthetic repair	DME Repair		Yes	Yes
L7520	Repair prosthetic device, labor component, per 15 minutes	DME: prosthetic repair	DME Repair		Yes	Yes
L8641	Metatarsal Joint Implant	Outpatient Surgery For Select Procedures	Surgery- Musculoskeletal		Yes	No
L8642	Hallux Implant	Outpatient Surgery For Select Procedures	Surgery- Musculoskeletal		Yes	No
L8699	Prosthetic Implant, Not Otherwise Specified	Outpatient Surgery For Select Procedures	Surgery- Musculoskeletal		Yes	No
L8600	Implantable breast prosthesis, silicone or equal	Reconstructive or cosmetic services - breast procedures	Surgery - breast	Preauthorization not required for treatment of cancer.	Yes	Yes
L8612	Aqueous shunt	DME: implant	DME Implant		Yes	Yes
L8679	Implantable neurostimulator , pulse generator, any type [when specified as sacral Nerve stimulator]	DME: implant	Nerve stimulator		Yes	Yes
L8680	Implantable neurostimulator electrode, each	DME: implant	Nerve stimulator		Yes	Yes
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only	Implant Supply	Nerve stimulator		Yes	Yes
L8682	Implantable neurostimulator radiofrequency receiver	DME: implant	Nerve stimulator		Yes	Yes
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver	Implant Supply	Nerve stimulator		Yes	Yes
L8684	Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement	Implant Supply	Nerve stimulator		Yes	Yes
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension	DME: implant	Nerve stimulator		Yes	Yes
L8686	Implantable neurostimulator pulse generator, single array, No rechargeable, includes extension	DME: implant	Nerve stimulator		Yes	Yes
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension	DME: implant	Nerve stimulator		Yes	Yes
L8688	Implantable neurostimulator pulse generator, dual array, Nonrechargeable, includes extension	DME: implant	Nerve stimulator		Yes	Yes
L8689	External recharging system for battery (internal) for use with implantable neurostimulator , replacement only	Implant Supply	DME supplies		Yes	Yes
L8690	Auditory osseointegrated device, includes all internal and external components	DME: equipment	DME device		Yes	No
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each	DME: equipment	DME device		Yes	No
L8693	Prosthetic Implant, Not Otherwise Specified	Outpatient Surgery For Select Procedures	Surgery- Musculoskeletal		Yes	No
L8693	Auditory osseointegrated device abutment, any length, replacement only	DME: equipment	DME device		Yes	No
Q0138	Inection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use)	Medical injectables/other non-injectable drugs	Medical specialty drugs	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
Q2041	Axicabtagene ciloleucel, up to 200 million Autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q2042	Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q2043	SIPULEUCEL-T, minimum of 50 million Autologous CD54+ cells activate with PAP-GM-CSF, including leukapheresis and all other Preparatory Procedures, per infusion	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	No	Yes
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q2054	Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q2055	Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q2056	Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5101	Injection, filgrastim -sndz, biosimilar, (zarxio) 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5103	Injection, infliximab-dyyb, biosimilar, (inflectra), 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5104	Injection, infliximab-abda, biosimilar (renflexis), 10mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5107	Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5108	Injection, pegfilgrastim-jmdb, (fulphila), biosimilar,0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5110	Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5111	Injection, pegfilgrastim-cbqv, (udenyca), biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5112	Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5113	Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5114	Injection, trastuzumab-dkst, biosimilar, (OGIVRI), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5115	Injection, rituximab-abbs, biosimilar (truxima), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5116	Injection, Trastuzumab-Qyyp, Biosimilar, (Trazimera), 10 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5117	Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5118	Injection, bevacizumab-bzvr, biosimilar, (zirabev), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5119	Injection, rituximab-pvvr, biosimilar (RUXIENCE), 10 mg	Medical injectables/other non-injectable drugs	Injection procedure	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
Q5120	Injection, pegfilgrastim-bmez, (ZIEXTENZO), biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds	Yes	Yes
Q5121	Injection, infliximab-AXXQ, biosimilar, (AVSOLA), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5122	Injection, pegfilgrastim-apgf, (nyvepria), biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5123	Injection, rituximab-arrx, biosimilar, (riabni), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5124	Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5125	Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5126	Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5127	Injection, pegfilgrastim-FPGK (stimufend), biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5128	Injection, ranibizumab-EQRN (cimeril), biosimilar, 0.1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5129	Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5130	Injection, pegfiLgrastim-PBBK (fylnetra), biosimilar, 0.5 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds.	Yes	Yes
Q5133	Injection, tocilizumab-bavi(tofidence), biosimilar, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5134	Injection, natalizumab-sztn, biosimilar, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5135	Injection, Tocilizumab-Aazg (Tyenne), Biosimilar, 1 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5136	Injection, Denosumab-Bbdz (Jubbonti/Wyost), Biosimilar, 1 Mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5137	Injection, ustekinumab-aaub (wezlana), biosimilar, subcutaneous, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5138	Injection, ustekinumab-aaub (wezlana), biosimilar, intravenous, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5139	Injection, eculizumab-aeeb (bkemv), biosimilar, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q5146	Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q9996	Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q9997	Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
Q9998	Injection, ustekinumab-aekn (selarsdi), 1 mg	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital BlueCross for Commercial.	Yes	No
S0157	Becaplermin gel 0.01%, 0.5 GM	Investigational and experimental procedures	Wound care	Not valid for Medicare	Yes	No
S0201	partial hospitalization services, less than 24 hours, per diem	select outpatient behavioral health services	behavioral health services	Not valid for Medicare purposes.	Yes	No
S0812	Phototherapeutic keratectomy (PTK)	Outpatient surgery for select procedures	Surgery - Eye	Not valid for Medicare	Yes	No
S1034	Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, Blood glucose device, insulin pump and computer algorithm that communicates with all of the devices	Diabetic DME & supplies	Diabetic Supplies		Yes	No
S1035	Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system	Diabetic DME & supplies	DME supplies		Yes	No
S1036	Transmitter; external, for use with artificial pancreas device system	Diabetic DME & supplies	DME supplies		Yes	No
S1037	Receiver (monitor); external, for use with artificial pancreas device system	Diabetic DME & supplies	DME supplies		Yes	No
S1040	Cranial remolding orthotic, pediatric, rigid, with soft interface material , custom fabricated, includes fitting and adjustment(s)	DME: equipment	Orthotics		Yes	No
S2053	Transplantation of small intestine, and liver allografts	Transplant surgeries	Organ/Tissue transplant - Intestine and Liver	Not valid for Medicare	Yes	No
S2054	Transplantation of multivisceral organs	Transplant surgeries	Organ/Tissue transplant - Multiple Organs	Not valid for Medicare	Yes	No
S2055	Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor	Transplant surgeries	Organ/Tissue transplant - Multiple Organs	Not valid for Medicare	Yes	No
S2060	Lobar lung transplantation	Transplant surgeries	Organ/Tissue transplant - Lung	Not valid for Medicare	Yes	No
S2061	Donor lobectomy (lung) for transplantation, living donor	Transplant surgeries	Organ/Tissue transplant - Lung	Not valid for Medicare	Yes	No
S2065	Simultaneous pancreas kidney transplantation	Transplant surgeries	Organ/Tissue transplant - Kidney	Not valid for Medicare	Yes	No
S2066	Breast reconstruction with gluteal artery perforator (gap) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral	Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare	Yes	No
S2067	Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral	Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare	Yes	No
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral	Reconstructive or cosmetic services: Breast procedures	Surgery - Breast Procedures	Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare	Yes	No
S2083	Adjustment of Gastric Band diameter via subcutaneous port by injection or aspiration of Saline	Outpatient services: Bariatric surgery	Surgery - Weight loss	Not valid for Medicare	Yes	No
S2112	Arthroscopy, knee, Surgical for Harvesting of Cartilage (Chondrocyte cells)	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
S2140	Cord Blood Harvesting for transplantation, allogeneic	Transplant surgeries	Blood or marrow stem cell transplants	Not valid for Medicare	Yes	No
S2142	Cord Blood-derived stem-cell transplantation, allogeneic	Transplant surgeries	Blood or marrow stem cell transplants	Not valid for Medicare	Yes	No
S2150	Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and posttransplant care in the global definition	Transplant surgeries	Blood or marrow stem cell transplants	Not valid for Medicare	Yes	No
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition	Transplant surgeries	Organ/Tissue transplant	Not valid for Medicare	Yes	No
S2202	Echosclerotherapy	Reconstructive or cosmetic services: Varicose veins	Varicose vein procedure	Not valid for Medicare	Yes	No
S2230	Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear	DME; Prosthetic appliance and implants	Hearing testing and treatment		Yes	No
S2348	Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
S2350	Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
S2351	Diskectomy ant w/osteophytes; lumbar ed add in interspace	Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	No
S3800	Genetic testing for Amyotrophic Lateral Sclerosis (ALS)	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3844	DNA analysis of the connexin 26 Gene (GJB2) for susceptibility to congenital, profound deafness	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3845	Genetic testing for alpha-thalassemia	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3846	Genetic testing for hemoglobin E beta-thalassemia	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3850	Genetic testing for sickle cell anemia	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3853	Genetic testing for myotonic muscular dystrophy	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3861	Genetic testing, sodium channel, voltage-gated, Type V, Alpha Subunit (SCN5A) and variants for suspected Brugada Syndrome	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3866	Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S3870	Comparative genomic hybridization (CGH) microarray testing for developmental delay, Autism Spectrum Disorder and/or intellectual disability	Diagnostic services: Genetic testing	Lab/Genetic testing	Not valid for Medicare	Yes	No
S8037	Magnetic Resonance Cholangiopancreatography (MRCP)	Diagnostic services: MRCP Scans	X-Ray/Imaging -MRI Scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	No
S8092	Electron beam computed tomography (Also known as Ultrafast CT, Cine CT)	Diagnostic services: CT scans	Investigational X-Ray/Imaging Cat Scan	This service is preauthorized through Evolent. - Traditional Products do not require preauthorization	Yes	No
S8948	Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes	other services: laser treatment	skin procedure		Yes	No
S8950	Complex Lymphedema therapy, each 15 minutes	Investigational and experimental procedures	Lymphedema therapy	Not valid for Medicare	Yes	No
S9055	Procuren or other growth factor preparation to promote wound healing	Investigational and experimental procedures	Wound care	Not valid for Medicare	Yes	No
S9340	Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9341	Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9342	Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9343	Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9434	Modified solid food supplements for inborn errors of metabolism	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9435	Medical foods for inborn errors of metabolism	Other services: enteral feeding and supplies	Special nutrient formula	Not valid for Medicare	Yes	No
S9480	Intensive outpatient psychiatric services, per diem	Select outpatient behavioral health services	Behavioral health services	Not valid for Medicare purposes.	Yes	No
S9960	Ambulance service, conventional air services, non emergency transport, one way (fixed wing)	Other services: Ambulance services -Non Emergent	Non emergency ambulance transport	Not valid for Medicare	Yes	No
S9961	Ambulance service, conventional air service, non emergency transport, one way (rotary wing)	Other services: Ambulance services -Non Emergent	Non emergency ambulance transport	Not valid for Medicare	Yes	No
T2007	Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2) hour increments	Other services: ambulance services - non emergent	Non emergency ambulance transport		Yes	Yes
V2785	Processing, preserving and transporting corneal tissue	Transplant surgeries	Organ/Tissue transplant		Yes	Yes
V5095	Semi-implantable middle ear hearing prosthesis	DME; Prosthetic appliance and implants	Hearing testing and treatment		Yes	No

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Single source preauthorization list

Benefits are subject to limitations in a member’s Benefits Booklet (Certificate of Coverage) and the member’s eligibility status.

The information being provided is based on information currently available in Capital Blue Cross' files.

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