Last Published 11.01.2024
This policy addresses ambulatory electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.
Last Published 11.01.2024
This policy addresses ambulatory electrocardiographic (AECG) diagnostic procedures. Applicable Procedure Codes: 33285, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272.
Last Published 02.01.2025
This policy addresses brow ptosis and eyelid repair. Applicable Procedure Codes: 21280, 21282, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Last Published 10.01.2024
This policy addresses capsule endoscopy and wireless gastrointestinal motility monitoring systems. Applicable Procedure Codes: 91110, 91111, 91112, 91299.
Last Published 02.01.2025
This policy addresses cardiovascular diagnostic and therapeutic procedures. Applicable Procedure Codes: 33267, 33268, 33269, 33289, 33477, 33999, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 93050, 93264, 93653, 93656, C2624.
Last Published 02.01.2025
This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures.
Last Published 02.01.2025
This policy addresses clinical diagnostic and preventive laboratory services and screenings.
Last Published 11.01.2024
This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Codes: 92548, 92549.
Last Published 10.01.2024
This policy addresses computerized corneal topography. Applicable Procedure Code: 92025.
,
Last Published 10.01.2024
This policy addresses cosmetic and reconstructive surgical services.
Last Published 02.01.2025
This policy addresses specific Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), and Medical Supplies.
Last Published 12.01.2024
This policy addresses balloon sinus ostial dilation, eustachian tube dilation, functional endoscopic sinus surgery (FESS), posterior nasal nerve ablation, intranasal repair, lithotripsy for salivary stones, rhinophototherapy, rhinophyma excision, septoplasty, rhinoplasty, and vestibular stenosis repair. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30520, 30540, 30545, 30620, 30999, 31240, 31242, 31243, 31253, 31254, 31257, 31259, 31287, 31288, 31295, 31296, 31297, 31298, 31299, 42699, 69799.
Last Published 10.01.2024
This policy addresses vagus nerve stimulation for treatment of chronic pain syndrome, percutaneous peripheral nerve stimulation (PNS), electrical stimulation for the treatment of dysphagia, percutaneous electrical nerve stimulation (PENS), percutaneous neuromodulation, and occipital nerve stimulation for the treatment of occipital neuralgia or headaches therapy (PNT). Applicable Procedure Codes: 61885, 61886, 63650, 64553, 64555, 64590, 64999, E0745, E0764, E0770.
Last Published 08.01.2024
This policy addresses experimental procedures and items, investigational devices, and clinical trials.
Last Published 10.01.2024
This policy addresses gastroesophageal and gastrointestinal (GI) services, procedures, and related devices. Applicable Procedure Codes: 0184T, 43647, 43648, 43881, 43882, 64590, 74261, 74262, 76497, 76498, 91132, 91133, 94595.
,
Last Published 10.01.2024
This policy addresses gender reassignment surgery for members with gender dysphoria.
Last Published 11.01.2024
This policy addresses hearing services and devices, including hearing aids and auditory implants. Applicable Procedure Codes: 69714, L7510, L8614, L8619, L8690, L8691, L8692.
Last Published 01.01.2025
This policy addresses home health, skilled care, and related services and supplies. Applicable Procedure Codes: 99503, 99505, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0299, G0300, G0493, G0494, G0495, G0496, G2168, G2169, T1000.
Last Published 01.01.2025
This policy addresses inpatient and outpatient hospital services, outpatient observation services, religious nonmedical health care institutions (RNHCIs), long term care hospitals (LTCH), never events, emergency and urgently needed services, post-stabilization care services, follow-up care services, and ambulance services.
Last Published 10.01.2024
This policy addresses intraocular telescope (implantable miniature telescope [IMT]) for treatment related to end-stage age-related macular degeneration. Applicable Procedure Codes: 0308T, C1840.
Last Published 12.01.2024
This policy addresses core decompression for avascular necrosis, hip/knee/elbow/shoulder replacement surgery (arthroplasty), Femoroacetabular Impingement (FAI) Syndrome, endoscopic cubital tunnel release, elbow, subacromial balloon spacers for the treatment of rotator cuff tears, and radiofrequency ablation of shoulder, hip, or knee. Applicable Procedure Codes: 21299, 23470, 23472, 23929, 23929, 24360, 24361, 24362, 24363, 24365, 25441, 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 27299, 27299, 27412, 27415, 27416, 27445, 27446, 27447, 27486, 27487, 27599, 27599, 27700, 27899, 28446, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, 29899, 29914, 29915, 29916, 29999, 29999, 29999, J7330.
Last Published 02.01.2025
This policy addresses outpatient medications/drugs, unlabeled use of Part B drugs, examples of covered and not covered medications/drugs, review at launch (RAL), and step therapy programs. Applicable Procedure Codes: 11980, J3490.
Last Published 10.01.2024
This policy addresses minimally invasive procedures for treating gastroesophageal reflux disease, including endoscopic procedures, the LINX® Reflux Management System, per oral endoscopic myotomy (POEM), and transoral incisionless fundoplication (TIF). Applicable Procedures Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999, 49999.
Last Published 02.01.2025
This policy addresses molecular pathology and genetic testing when reported with unlisted codes. Applicable Procedure Codes: 81479, 81599, 84999.
Last Published 02.01.2025
This policy addresses molecular and genetic tests that have proven efficacy in the diagnosis or treatment of medical conditions.
Last Published 10.01.2024
This policy addresses neurologic services and procedures. Applicable Procedure Codes: 64568, 64999, 95965, 95966, C1827.
,
Last Published 10.01.2024
This policy addresses noninvasive fractional flow reserve (FFR) derived from coronary computed tomography angiography (CCTA), also known as FFR-ct, for the evaluation of ischemic heart disease/coronary artery disease. Applicable Procedure Codes: 0501T, 0502T, 0503T, 0504T, 75580.
Last Published 01.01.2025
This policy addresses certain items/services that do not have Medicare coverage criteria.
Last Published 12.01.2024
This policy addresses athletic pubalgia surgery, computer-assisted surgical navigation for musculoskeletal procedures, extracorporeal shock wave therapy (ESWT), kinesio taping, manipulation under anesthesia (MUA), and unicondylar spacer devices. Applicable Codes: 0054T, 0055T, 0101T, 0102T, 20985, 22505, 27198, 27299, 27599, 27599, 28890, 29799, 49659, 49999, 97139, 97799, A9999.
Last Published 10.01.2024
This policy addresses osteopathic manipulative treatments (OMT). Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929.
Last Published 10.01.2024
This policy addresses pain management, inpatient and outpatient pain rehabilitation programs, and related services. Applicable Procedure Codes: 0440T, 0441T, 0442T, 22899, 27599, 64405, 64454, 64624, 64625, 64628, 64629, 64722, 64744, 64999.
Last Published 10.01.2024
This policy addresses percutaneous coronary intervention (PCI). Applicable Procedure Codes: 92920, 92924, 92928, 92933, 92937, 92941, 92943, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608.
,
Last Published 11.01.2024
This policy addresses percutaneous insertion of an endovascular cardiac (ventricular) assist device. Applicable Procedure Codes: 33990, 33991, 33995.
Last Published 02.01.2025
This policy addresses pharmacogenomics testing (PGx). Applicable Procedure Codes: 0031U, 0032U, 0033U, 0117U, 0173U, 0175U, 81230, 81346, 81355.
Last Published 12.01.2024
This policy addresses platelet rich plasma injections/applications for the treatment of musculoskeletal injuries or joint conditions. Applicable Procedure Codes: 0232T, G0460, G0465, P9020.
Last Published 12.01.2024
This policy addresses positron emission tomography (PET) scans for myocardial imaging.
Last Published 10.01.2024
This policy addresses services and procedures for the diagnosis and treatment of prostate conditions and related impotence treatment. Applicable Codes: 37243, 52441, 52442, 53855, 55874, 55899, 55899, 64999, L8699.
,
Last Published 12.01.2024
This policy addresses high-dose rate electronic brachytherapy, implantable beta-emitting microspheres for treatment of malignant tumors, transarterial chemoembolization, image guided radiation therapy (IGRT), special/associated services, standard radiation therapy (2D/3D), proton beam therapy (PBT), intensity modulated radiation therapy (IMRT), stereotactic radiosurgery/stereotactic body radiation therapy (SBRT), intraoperative hyperthermic intraperitoneal chemotherapy, and intraoperative radiation treatment (IORT) . Applicable Procedure Codes: 0394T, 0395T, 37243, 37243, 67299, 77014, 77331, 77370, 77371, 77372, 77373, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77424, 77425, 77469, 77470, 77520, 77522, 77523, 77525, 79445, 92499, 0394T, G0339, G0340, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 02.01.2025
This policy addresses diagnostic radiological services. Applicable Procedure Codes: 76376, 76377, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78099, 78199, 78226, 78227, 78299, 78399, 78451, 78452, 78469, 78494, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78608, 78699, 78799, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78999.
Last Published 02.15.2025
This policy addresses outpatient rehabilitation therapy (including physical therapy, occupational therapy, and speech-language pathology services), inpatient rehabilitation services, and other rehabilitation therapy services. Applicable Procedure Codes: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97035, 97036, 97110, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97550, 97755, 97761, 97799, G0283.
,
Last Published 02.03.2025
This policy addresses skin substitutes grafts/cellular and tissue-based products (CTP) and amniotic/placental derived product injections and/or applications for non-wound musculoskeletal indications.
"A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2017, A2018, A2019, A2021, A4100, Q4100, Q4110, Q4111, Q4112, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4125, Q4126, Q4127, Q4130, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4310, Q4318, Q4326, Q4331, and Q4332."
Last Published 11.01.2024
This policy addresses sleep apnea surgical treatments. Applicable Procedure Codes: 21141, 21145, 21196, 21199, 21685, 41512, 41530, 41599, 42145.
Last Published 02.01.2025
This policy addresses the implantation of spinal cord stimulators (SCS) for the relief of chronic intractable pain. Applicable Procedure Codes: 63650, 63655, 63685.
Last Published 12.01.2024
This policy addresses lumbar spinal fusion, cervical spinal fusion, allograft or synthetic bone graft materials, spinal decompression, interspinous process decompression, interlaminar lumbar instrumented fusion (ILIF), and percutaneous minimally invasive fusion. Applicable Procedure Codes: 0165T, 0200T, 0201T, 0219T, 0220T, 0221T, 0222T, 20930, 20931, 22206, 22207, 22212, 22222, 22214, 22224, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22556, 22558, 22610, 22612, 22630, 22633, 27279, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22842, 22849, 22850, 22852, 22854, 22855, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22867, 22868, 22869, 22870, 22899, 62287, 63003, 63005, 63012, 63016, 63017, 63030, 63042, 63046, 63047, 63050, 63051, 63055, 63056, 63064, 63077, 63085, 63087, 63090, 63101, 63102, 63170, 63173, 63185, 63190, 63191, 63197, 63200.
Last Published 12.01.2024
This policy addresses multiple surgical procedures that utilize InterQual® coverage guidelines when no Medicare coverage criteria exists.
Last Published 02.01.2025
This policy addresses Tier 2 molecular pathology procedures, which are procedures not identified by Tier 1 molecular pathology procedures or other CPT codes. Applicable Procedure Codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408.
Last Published 12.01.2024
This policy addresses temporomandibular joint (TMJ) treatment. Applicable Procedure Codes: 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21240, 21242, 21244, 21245, 21246, 21247, 21247, 97039, 97139.
Last Published 10.01.2024
This policy addresses diagnosis, treatments, and devices for urinary and fecal incontinence. Applicable Codes: 0672T, 53860, 53899, 55899, 58999, 64561, 64581, 64590, 64595, E2001.
Last Published 02.01.2025
This policy addresses molecular urogenital/anogenital (UG/AG) panels for infectious disease pathogen identification testing. Applicable Procedure Codes: 0352U, 81513, 81514.
Last Published 02.01.2025
This policy addresses uterine services and procedures. Applicable Procedure Codes: 0071T, 0072T, 37243, 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58662, 58999, 59812, 59840.
Last Published 10.01.2024
This policy addresses treatment of varicose veins including stab phlebectomy less than 10 incisions, endomechanical ablation of incompetent extremity veins, and embolization of the ovarian and iliac veins for pelvic congestion syndrome. Applicable Procedure Codes: 36473, 36474, 37241, 37799.
Last Published 12.01.2024
This policy addresses testing for vitamin D deficiency. Applicable Procedure Code: 82652.