YourCare Health Plan 2015 CPT Code/Prior Authorization List

(1)

Medicaid,

CHP

Radiology MRI

₇₀₃₃₆

MRI TMJ Tempomandibular joint/jaw _{PA Medical Necessity Review}

Radiology CT SCANS

₇₀₄₅₀

CT Head/Brain w/o Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₇₀

CT Head/Brain w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₀

CT Orbit w/o Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₁

CT Orbit w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₂

CT Orbit w/o & w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₆

CT Maxllfcl w/o Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₇

CT Maxllfcl w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

Radiology CT SCANS

₇₀₄₈₈

CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review Radiology CT SCANS

₇₀₄₈₈

CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review Radiology CT SCANS

₇₀₄₉₀

CT Soft Tissue Neck w/o Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review Radiology CT SCANS

₇₀₄₉₁

CT Soft Tissue Neck w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review Radiology CT SCANS

70492

CT Soft Tissue Neck w/o & w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review

Radiology CT SCANS

70496

Ct Angiography Head PA Medical Necessity Review

Radiology CT SCANS

70498

Ct Angiography Neck PA Medical Necessity Review

Radiology MRI

70540

MRI Face, Orbit, Neck w/o Contrast Sinus/3 areas (soft tissue neck) _{eyes/temporal} PA Medical Necessity Review

Radiology MRI

₇₀₅₄₂

MRI Face, Orbit, Neck w/ Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₀₅₄₃

MRI Face, Orbit, Neck w & w/o Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₄

MRA Head w/o Contrast Also known as MRV _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₅

MRA Head w/ Contrast Gadolinium/ Also known as MRV _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₆

MRA Head w & w/o Contrast Gadolinium/ Also known as MRV _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₇

MRA Neck w/o Contrast Also known as MRV _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₈

MRA Neck w/ Contrast Gadolinium/ Also known as MRV _{PA Medical Necessity Review}

Radiology MRA

₇₀₅₄₉

MRA Neck w & w/o Contrast Gadolinium/ Also known as MRV _{PA Medical Necessity Review}

Radiology MRI

₇₀₅₅₁

MRI Head w/o Contrast IACs (Internal Auditory Canal) _{PA Medical Necessity Review}

Radiology MRI

₇₀₅₅₂

MRI Head w/ Contrast IACs (Internal Auditory Canal) _{PA Medical Necessity Review}

(2)

Medicaid,

CHP

Radiology MRI

70554

MRI, Brain, Functional MRI; Including Test Selection and Administration of Repetitive Body Part Movement and/or Visual Stimulation, Not Requiring Physician or Psychologist Administration PA Medical Necessity Review Radiology MRI

70555

MRI, Brain, Functional MRI; Requiring Physician or Psychologist Administration of Entire Neurofunctional Testing PA Medical Necessity Review

Radiology CT SCANS

₇₁₂₅₀

CT Thorax w/o Contrast Can be CT Chest or a Ultrafast‐CT/EBT/EBCT PA Medical Necessity Review

Radiology CT SCANS

₇₁₂₆₀

CT Thorax w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review

d l

₇₁₂₇₀

CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT d l

Radiology CT SCANS

₇₁₂₇₀

CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review

Radiology CT SCANS

₇₁₂₇₅

Ct Angiography Chest PA Medical Necessity Review

Radiology MRI

₇₁₅₅₀

MRI Chest w/o Contrast Brachial Plexus _{PA Medical Necessity Review}

Radiology MRI

₇₁₅₅₁

MRI Chest w/ Contrast _{PA Medical Necessity Review}

Radiology MRI

₇₁₅₅₂

MRI Chest w/ & w/o Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRA

71555

MRA Chest (Emc Myocardium) w/ or w/o _Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₂₆

CT C Spine w/ Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₂₇

CT C Spine w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₂₈

CT T Spine w/o Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₂₉

CT T Spine w/ Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₃₀

CT T Spine w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₃₂

CT L Spine w/ Contrast Includes Sacrum PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₃₃

CT L Spine w/o & w/ Contrast Includes Sacrum PA Medical Necessity Review

Radiology MRI

₇₂₁₄₁

MRI Cervical Spine w/o Contrast Vertebrae of the Neck _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₄₂

MRI Cervical Spine w/ Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₄₆

MRI Thoracic Spine w/o Contrast _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₄₇

MRI Thoracic Spine w/ Contrast Gadolinium _{PA Medical Necessity Review}

(3)

Medicaid,

CHP

Radiology MRI

₇₂₁₄₉

MRI Lumbar Spine w/ Contrast Gadolinium ‐ Includes Sacrum _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₅₆

MRI C Spine w/ & w/o Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₅₇

MRI T Spine w/ & w/o Contrast Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₅₈

MRI L Spine w/ & w/o Contrast Gadolinium ‐ Includes Sacrum _{PA Medical Necessity Review} Radiology MRA

₇₂₁₅₉

MRA Spinal Canal w/ or w/o Contrast Gadolinium/ Also known as MRV _{Excluded from program}

Radiology CT SCANS

₇₂₁₉₁

CT Angiography Pelvis Aortic Aneurysm Excluded from program

Radiology CT SCANS

₇₂₁₉₂

CT Pelvis w/o Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₉₃

CT Pelvis w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology CT SCANS

₇₂₁₉₄

CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review Radiology CT SCANS

₇₂₁₉₄

CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology MRI

₇₂₁₉₅

MRI Pelvis w/o Contrast Coccyx _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₉₆

MRI Pelvis w/ Contrast Gadolinium/coccyx _{PA Medical Necessity Review}

Radiology MRI

₇₂₁₉₇

MRI Pelvis w & w/o Contrast Gadolinium/coccyx _{PA Medical Necessity Review}

Radiology MRA

₇₂₁₉₈

MRA Pelvis w/ or w/o Contrast Gadolinium/ Also known as MRV _{Excluded from program}

Radiology CT SCANS

73200

CT Upper Extremity w/o Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review Radiology CT SCANS

₇₃₂₀₁

CT Upper Extremity w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review Radiology CT SCANS

₇₃₂₀₂

CT Upper Extremity w/o & w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review Radiology CT SCANS

₇₃₂₀₆

CT Angiography Upper Extremity Hand/Arm/Shoulder/ Elbow/Wrist Excluded from program

Radiology MRI

₇₃₂₁₈

MRI Upper Extremity w/o Contrast Hand/Arm/Axilla _{PA Medical Necessity Review}

Radiology MRI

₇₃₂₁₉

MRI Upper Extremity w/ Contrast Hand/Arm/Axilla‐Gadolinium _{PA Medical Necessity Review} Radiology MRI

₇₃₂₂₀

MRI Upper Extremity w & w/o Contrast Hand/Arm/Axilla‐Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₃₂₂₁

MRI Upper Extremity w/o Contrast Shoulder/Elbow/Wrist _{PA Medical Necessity Review}

Radiology MRI

73222

MRI Upper Extremity w/ Contrast Arthrogram_{Shoulder/Elbow/Wrist‐Gadolinium} PA Medical Necessity Review Radiology MRI

₇₃₂₂₃

MRI Upper Extremity Joint w & w/o Contrast Shoulder/Elbow/Wrist‐Gadolinium _{PA Medical Necessity Review} Radiology MRA

₇₃₂₂₅

MRA Upper Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV _{Excluded from program} Radiology CT SCANS

₇₃₇₀₀

CT Lower Extremity w/o Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review Radiology CT SCANS

₇₃₇₀₁

CT Lower Extremity w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review

(4)

Medicaid,

CHP

Radiology CT SCANS

₇₃₇₀₂

CT Lower Extremity w/o & w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review

Radiology CT SCANS

₇₃₇₀₆

CT Angiography Lower Extremity Hip/Leg/Knee/Ankle/ Foot Excluded from program

Radiology MRI

₇₃₇₁₈

MRI Lower Extremity w/o Contrast Foot/Leg _{PA Medical Necessity Review}

Radiology MRI

₇₃₇₁₉

MRI Lower Extremity w/ Contrast Foot/Leg‐Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₃₇₂₀

MRI Lower Extremity w/ & w/o Contrast Foot/Leg‐Gadolinium _{PA Medical Necessity Review}

Radiology MRI

₇₃₇₂₁

MRI Lower Extremity w/o Contrast Hip/Knee/Ankle _{PA Medical Necessity Review}

Radiology MRI

73722

MRI Lower Extremity w/ Contrast Arthrogram_{Hip/Knee/Ankle‐Gadolinium} PA Medical Necessity Review Radiology MRI

₇₃₇₂₃

MRI Lower Extremity Joint w/ & w/o Contrast Hip/Knee/Ankle‐Gadolinium _{PA Medical Necessity Review} Radiology MRA

₇₃₇₂₅

MRA Lower Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV _{Excluded from program}

Radiology CT SCANS

₇₄₁₅₀

CT Abdomen w/o Contrast Diaphragm to Belly Button PA Medical Necessity Review

Radiology CT SCANS

₇₄₁₆₀

CT Abdomen w/ Contrast Aneurysm/Diaphragm to Belly Button PA Medical Necessity Review Radiology CT SCANS

₇₄₁₇₀

CT Abdomen w/o & w/ Contrast Diaphragm to Belly Button PA Medical Necessity Review

Radiology CT SCANS

74174

Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Excluded from program

Radiology CT SCANS

₇₄₁₇₅

Ct Angiography Abdomen Diaphragm to Belly Button Excluded from program

Radiology MRI

₇₄₁₈₁

MRI Abdomen w/o Contrast MRCP‐MR Cholangiogram _{PA Medical Necessity Review}

Radiology MRI

₇₄₁₈₂

MRI Abdomen w/ Contrast MRCP‐MR Cholangiogram Gadolinium _{PA Medical Necessity Review} Radiology MRI

₇₄₁₈₃

MRI Abdomen w/ & w/o Contrast MRCP‐MR Cholangiogram Gadolinium _{PA Medical Necessity Review}

Radiology MRA

₇₄₁₈₅

MRA Abdomen w/ or w/o Contrast Also known as MRV _{Excluded from program}

Radiology MRI

75557

Cardiac MRI For Morphology And Function _{Without Contrast Material} Excluded from program

Radiology MRI

75559

Cardiac MRI For Morphology And Function Without Contrast Material; With Stress Imaging Excluded from program Radiology MRI

75561

Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences Excluded from program

(5)

Medicaid,

CHP

Radiology MRI

75563

Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences; With Stress Imaging Excluded from program

Radiology CT SCANS

₇₆₃₈₀

CT Limited or Localized Follow‐Up Study Excluded from program

Radiology MRI

₇₆₃₉₀

MRI Spectroscopy MRS _{Excluded from program}

Radiology CT SCANS

₇₆₄₉₇

Unlisted Computed Tomography Procedure Excluded from program

Radiology MRI

₇₆₄₉₈

Unlisted MRI Procedure _{Redirect to valid code}

Radiology MRI

₇₆₄₉₉

Unlisted Radiologic Procedure _{Excluded from program}

Radiologygy ULTRASOUND U/S OB Pelvis, Pregnant Uterus, First Trimester

76801

/ , g , <14 Weeks Single Or First Gestation Excluded from program Radiology ULTRASOUND

76802

U/S OB Pelvis, Pregnant Uterus, First Trimester <14 Weeks Each Additional Gestation Multiple Gestation only Excluded from program Radiology ULTRASOUND

76805

U/S OB Pelvis, Pregnant Uterus, B‐Scan (Allowed _{Once Per Gestation)} Level 1 Excluded from program

Radiology ULTRASOUND

76810

U/S OB Pelvis Complete, Multiple Gestation after 1st Trimester (Allowed Once For Each Additional Fetus per Gestation; Must Be Billed With 76805) Multiple Gestation only Excluded from program Radiology ULTRASOUND

76811

US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Single or First Gestation (Allowed Once Per Gestation; Second Study Allowed If Performed By A Different Physician) Level 2 Excluded from program Cardiology CARDIAC IMPLANTABLES

33206

Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₀₇

Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Ventricular PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

33208

Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial And Ventricular PA Medical Necessity Review

(6)

Medicaid,

CHP

Cardiology CARDIAC IMPLANTABLES

₃₃₂₁₂

Insertion or Replacement of Permanent Pacemaker Pulse Generator Only; Single Chamber, Atrial or Ventricular PA Medical Necessity Review Radiology ULTRASOUND

76812

US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Each Additional Gestation (Allowed Once For Each Additional Fetus Per Gestation; Must Be Billed With 76811; Second Study Allowed If Performed By A Different Physician) Multiple Gestation only Excluded from program

Radiology ULTRASOUND Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or

76813

y , transvaginal approach; single or first gestation. (Allowed once per gestation) Excluded from program Radiology ULTRASOUND

76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) (Allowed once for each additional fetus per gestation) Excluded from program Radiology ULTRASOUND

76815

U/S Pregnant Uterus, Real Time w/ Image Documentation, Limited (E.G. Fetal Heart Beat, Placental Location, Fetal Position and/or Qualitative Amniotic Fluid Volume), 1 or More Fetuses One CPT code per DOS regardless the # of fetuses Excluded from program

₇₆₈₁₆

U/S OB Pelvis Follow Up or Repeat One exam per fetus _{Excluded from program}

76817

US Pregnant Uterus Transvaginal One CPT code per DOS regardless the # of _fetuses Excluded from program

(7)

Medicaid,

CHP

76819

Fetal Biophysical Profile w/o Stress Non Stress One exam per fetus Excluded from program Radiology ULTRASOUND

₇₆₈₂₀

Doppler Velocimetry, Fetal; Umbilical Artery One exam per fetus _{Excluded from program}

76821

Doppler Velocimetry, Fetal; Middle Cerebral _Artery One exam per fetus Excluded from program

76825

U/S OB Echocardiography, Fetal, Cardiovascular _System Fetal Echo_{One exam per fetus} Excluded from program

₇₆₈₂₆

Follow Up or Repeat Study One exam per fetus _{Excluded from program}

₇₆₈₂₇

Doppler Echocardiography Fetal Complete One exam per fetus _{Excluded from program}

₇₆₈₂₈

Follow Up or Repeat Study One exam per fetus _{Excluded from program}

R di l ULTRASOUND U/S G i i l E d i

₇₆₉₇₅

U/S Gastrointestinal, Endoscopic _{Excluded from program}

Radiology CT SCANS

₇₇₀₁₁

CT Guidance Sterotactic Localization Excluded from program

Radiology CT SCANS

₇₇₀₁₂

CT Guidance Needle BX‐RAD S & I Excluded from program

Radiology CT SCANS

₇₇₀₁₃

CT Guidance for and Monitoring of Tissue

Ablation Excluded from program

Radiology CT SCANS

77014

CT Guidance for Placement of Radiation Therapy _Fields Excluded from program

Radiology MRI

₇₇₀₂₁

MRI Guidance for Needle Placement _{Excluded from program}

Radiology MRI

77022

MRI Guidance for and Monitoring of Tissue _Ablation Excluded from program

Radiology MRI

77058

MRI Breast w/ and/or w/o Contrast; Unilateral Unilateral‐One‐Gadolinium PA Medical Necessity Review

Radiology MRI

₇₇₀₅₉

MRI Breast Bilateral Both _{PA Medical Necessity Review}

Radiology CT SCANS

₇₇₀₇₈

CT Bone Density Study, Axial Skeleton Excluded from program

Radiology CT SCANS

77079

CT Bone Density Study, Appendicular Skeleton Excluded from program

Radiology MRI

₇₇₀₈₄

MRI Bone Marrow Blood Supply _{Excluded from program}

Radiology NUCLEAR MED

₇₈₀₀₀

Thyroid uptake; single determination _{Redirect to valid code}

₇₈₀₀₁

Thyroid uptake; multiple determinations _{Redirect to valid code}

78003

Thyroid uptake stimulation, suppression or

(8)

Medicaid,

CHP

78006

Thyroid imaging, with uptake; single _{determination} Redirect to valid code

₇₈₀₀₇

Thyroid imaging, multiple determinations _{Redirect to valid code}

₇₈₀₁₀

Thyroid imaging; only _{Redirect to valid code}

₇₈₀₁₁

Thyroid imaging; with vascular flow _{Redirect to valid code}

78012

Thyroid Uptake, Single or Multiple Quantitative Measurements(s) (Including Stimulation, Suppression, or Discharge, When Performed) Excluded from program Radiology NUCLEAR MED

78013

Thyroid Imaging (Including Vascular Flow, When Performed) Excluded from program

78013

Performed) p g Radiology NUCLEAR MED

78014

Thyroid Imaging (Including Vascular Flow, When Performed); With Single or Multiple Uptake(s) Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed) Excluded from program

₇₈₀₁₅

Thyroid Met Imaging _{Excluded from program}

₇₈₀₁₆

Thyroid Met Imaging with Additional Studies _{Excluded from program}

₇₈₀₁₈

Thyroid Scan Whole Body For CA thyroid (I‐ 31 scan) _{Excluded from program}

₇₈₀₂₀

Thyroid Carcinoma Metastases Uptake _{Excluded from program}

78070

Parathyroid Planar Imaging (Including Subtraction, When Performed)

Excluded from program

₇₈₀₇₅

Adrenal Nuclear Imaging MIBG _{Excluded from program}

₇₈₀₉₉

Unlisted Endocrine Procedure _{Excluded from program}

₇₈₁₀₂

Bone Marrow Imaging, Limited _{Excluded from program}

₇₈₁₀₃

Bone Marrow Imaging, Multiple _{Excluded from program}

₇₈₁₀₄

Bone Marrow Imaging, Whole Body _{Excluded from program}

₇₈₁₃₅

Differential Organ/Tissues Kinetic _{Excluded from program}

(9)

Medicaid,

CHP

₇₈₁₈₅

Spleen Imaging w & w/o Vascular Flow _{Excluded from program}

₇₈₁₉₀

Platelet Survival, Kinetics _{Excluded from program}

₇₈₁₉₁

Platelet Survival _{Excluded from program}

₇₈₁₉₅

Lymph System Imaging MIBG _{Excluded from program}

₇₈₁₉₉

Unlisted Hematopoetic Procedure _{Excluded from program}

₇₈₂₀₁

Liver Imaging _{Excluded from program}

₇₈₂₀₂

Liver Imaging w/ Flow _{Excluded from program}

₇₈₂₀₅

Liver Imaging Spect _{Excluded from program}

₇₈₂₀₆

Liver Imaging Spect w/ Vascular Flow _{Excluded from program}

₇₈₂₀₆

Liver Imaging Spect w/ Vascular Flow _{Excluded from program}

₇₈₂₁₅

Liver and Spleen Imaging Red Cell Tagging _{Excluded from program}

₇₈₂₁₆

Liver and Spleen Imaging w/ Flow _{Excluded from program}

78226

Hepatobiliary system imaging, including _{gallbladder when present;} Excluded from program

78227

Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed Excluded from program

₇₈₂₃₀

Salivary Gland Imaging _{Excluded from program}

₇₈₂₃₁

Serial Salivary Gland _{Excluded from program}

₇₈₂₃₂

Salivary Gland Function Test _{Excluded from program}

₇₈₂₅₈

Esophagus Motility Study _{Excluded from program}

₇₈₂₆₁

Gastric Mucosa Imaging _{Excluded from program}

₇₈₂₆₂

Gastroesophagael Reflum Emam _{Excluded from program}

₇₈₂₆₄

Gastric Emptying Study _{Excluded from program}

₇₈₂₇₈

GI Bleeder Scan _{Excluded from program}

₇₈₂₈₂

GI Protein Loss Exam _{Excluded from program}

₇₈₂₉₀

Meckel's Diverticulum Imaging _{Excluded from program}

(10)

Medicaid,

CHP

₇₈₂₉₉

Unlisted Gastroinestinal Procedure _{Excluded from program}

₇₈₃₀₀

Bone or Joint Imaging Ltd One Bone _{Excluded from program}

₇₈₃₀₅

Bone or Joint Imaging Multiple More than one Bone _{Excluded from program}

₇₈₃₀₆

Bone Scan Whole Body Used Often with CA studies/All bones _{Excluded from program}

78315

Bone and/or Joint Imaging; 3 Phase Study Osteomyelitis_{Technesium 99} Excluded from program

₇₈₃₂₀

Bone Joint Imaging Tomo Test Spect _{Excluded from program}

₇₈₃₉₉

Unlisted Musculoskeletal Procedure _{Excluded from program}

₇₈₄₁₄

Non‐Imaging Heart Function _{Excluded from program}

₇₈₄₂₈

Cardiac Shunt Imaging _{Excluded from program}

₇₈₄₄₅

Radionuclide Venogram Non‐Cardiac _{Excluded from program}

₇₈₄₅₆

Acute Venous Thrombosis Imaging _{Excluded from program}

₇₈₄₅₇

Venous Thrombosis Imaging Unilateral _{Excluded from program}

₇₈₄₅₈

Venous Thrombosis Imaging Bilateral _{Excluded from program}

Radiology PET SCANS

78459

Myocardial Imaging, Positron Emission _{Tomography (PET) Metabolic Eval.} PA Medical Necessity Review

₇₈₄₆₆

Myocardial Infarction Scan _{Excluded from program}

₇₈₄₆₈

Heart Infarct Image Ef _{Excluded from program}

₇₈₄₆₉

Heart Infarct Image Spect _{Excluded from program}

₇₈₄₇₂

Gated Heart, Rest or Stress _{Excluded from program}

₇₈₄₇₃

Cardiac Blood Pool Muga Scan _{Excluded from program}

₇₈₄₈₁

Heart First Pass Single _{PA Medical Necessity Review}

₇₈₄₈₃

Cardiac Blood Pool Imaging, Multi _{PA Medical Necessity Review}

Radiology PET SCANS

78491

Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Single Study At Rest Or Stress PA Medical Necessity Review Radiology PET SCANS

78492

Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Multiple Studies At Rest Or Stress PA Medical Necessity Review

(11)

Medicaid,

CHP

₇₈₄₉₄

Cardiac Blood Pool Imaging, Spect _{PA Medical Necessity Review}

₇₈₄₉₆

Cardiac Blood Pool Imaging, Single at Rest _{PA Medical Necessity Review}

₃₃₂₁₃

Insertion Of Pacemaker Pulse Generator Only;

With Existing Dual Leads PA Medical Necessity Review

₇₈₄₉₉

Unlisted Cardiovascular Procedure _{Excluded from program}

₃₃₂₁₄

Upgrade Of Implanted Pacemaker System, Conversion Of Single Chamber System To Dual Chamber System (Includes Removal Of Previously Placed Pulse Generator, Testing Of Existing Lead, Insertion Of New Lead, Insertion Of New Generator) PA Medical Necessity Review ) Radiology NUCLEAR MED

78579

Pulmonary ventilation imaging (eg, aerosol or gas) Excluded from program Radiology NUCLEAR MED

78580

Pulmonary perfusion imaging (eg, particulate); Excluded from program Radiology NUCLEAR MED

78582

Pulmonary ventilation (eg, aerosol or gas) and _{perfusion imaging} Excluded from program

78597

Quantitative differential pulmonary perfusion, including imaging when performed Excluded from program Radiology NUCLEAR MED

78598

Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Excluded from program

₇₈₅₉₉

Unlisted Respiratory Procedure _{Excluded from program}

₇₈₆₀₀

Brain Imaging Ltd Static _{Excluded from program}

₇₈₆₀₁

Brain Ltd Imaging and Flow _{Excluded from program}

₇₈₆₀₅

Brain Imaging Complete _{Excluded from program}

₇₈₆₀₆

Brain Imaging Complete w/ Flow _{Excluded from program}

₇₈₆₀₇

Brain Imaging Spect SPECT _{Excluded from program}

Radiology PET SCANS

(12)

Medicaid,

CHP

Radiology PET SCANS

78609

Brain Imaging, Positron Emission Tomography _{(PET) Perfusion Evaluation} PA Medical Necessity Review

₇₈₆₁₀

Brain Flow Imaging Only _{Excluded from program}

₇₈₆₃₀

Cisternogram (Cerebrospinal Fluid Flow) _{Excluded from program}

₇₈₆₃₅

Cerebrospinal Ventriculography _{Excluded from program}

₇₈₆₄₅

CSF Shunt Evaluation _{Excluded from program}

₇₈₆₄₇

Cerebrospinal Fluid Scan Spect _{Excluded from program}

₇₈₆₅₀

CSF Leakage Detection and Localization _{Excluded from program}

₇₈₆₆₀

Radiopharmaceutical Dacryocystorgraphy _{Excluded from program}

₇₈₆₉₉

Unlisted Nuclear Medicine Procedure _{Excluded from program}

₇₈₇₀₀

Kidney Imaging Morphology _{Excluded from program}

78701

Kidney Imaging Morphology w/ Vascular Flow Excluded from program

78707

Kidney Imaging Morphology w/ Vascular Flow _{and Function Study} Renal Scan Excluded from program

78708

Kidney Imaging Morphology w/ Vascular Flow

and Function, Single w/ Pharm Intervention Excluded from program

78709

Kidney Imaging Morphology w/ Vascular Flow, _{Multi, w/o and w/ Pharm Intervention} Captorpril/Renal Scan/MAG 3 Excluded from program

₇₈₇₁₀

Kidney Imaging, Spect _{Excluded from program}

78725

Kidney Function Study, Non‐Image Radioisotropic Excluded from program

₇₈₇₃₀

Urinary Bladder Residual Study _{Excluded from program}

₇₈₇₄₀

Ureteral Reflum Study VCUG/Cystogram _{Excluded from program}

₇₈₇₆₁

Testicular Imaging w/ Vascular Flow _{Excluded from program}

₇₈₇₉₉

Unlisted Genitourinary Procedure _{Excluded from program}

78800

Radiopharm Localization of Tumor, Limited Area Excluded from program

(13)

Medicaid,

CHP

78802

Radiopharm Localization of Tumor, Whole Body Gallium Scan/Octreo Scan Excluded from program Radiology NUCLEAR MED

₇₈₈₀₃

Radiopharm Localization of Tumor, Spect Gallium Scan/FUO _{Excluded from program}

78804

Radiopharmaceutical Localization of Tumor or Distribution of Radiopharmaceutical Agent(s); Whole Body, Requiring 2 or More Days Imaging Excluded from program Radiology NUCLEAR MED

78805

Radiopharm Localization of Abscess, Limited Area Gallium Scan/Indium Scan/WBC Scan/MBIG Excluded from program

78806

Radiopharm Localization of Abscess, Whole Body Gallium Scan/Indium Scan/WBC Scan/MBIG Excluded from program Radiology NUCLEAR MED Radiopharm Localization of Abscess Spect Galliium Scan/Indium Scan/WBC Scan/MBIG

78807

Radiopharm Localization of Abscess, Spect Galliium Scan/Indium Scan/WBC Scan/MBIG Excluded from program

Radiology PET SCANS

78811

Positron Emission Tomography (PET) Imaging;

Limited Area (Eg, Chest, Head/Neck) PA Medical Necessity Review

Radiology PET SCANS

78812

Positron Emission Tomography (PET) Imaging; _{Skull Base To Mid‐Thigh} PA Medical Necessity Review

Radiology PET SCANS

78813

Positron Emission Tomography (PET) Imaging; _Whole Body PA Medical Necessity Review

Radiology PET SCANS

78814

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Limited Area (Eg Chest, Head/Neck) PET with CT PA Medical Necessity Review Radiology PET SCANS

78815

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Skull Base to Mid‐Thigh PET with CT PA Medical Necessity Review Radiology PET SCANS

78816

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Whole Body PET with CT PA Medical Necessity Review Radiology NUCLEAR MED

(14)

Medicaid,

CHP

Radiology T‐CODES

0042T

CT Perfusion Brain Investigational Radiology T‐CODES

0159T

Computer‐Aided Detection, Including Computer Algorithm Analysis of MRI Image Data For Lesion Detection/Characterization, Pharmacokinetic Analysis, with Further Physician Review for Interpretation, Breast MRI (List Separately In Addition To Code For Primary Procedure) Not Covered

Radiology CT SCANS

₇₀₄₆₀

CT Head/Brain w/ Contrast PA Medical Necessity Review

Radiology _CT SCANS

₇₂₁₂₅

CT C Spine w/o Contrast _{PA Medical Necessity Review}_y

Radiology CT SCANS

₇₂₁₃₁

CT L Spine w/o Contrast PA Medical Necessity Review

Radiology CT SCANS

₇₄₁₇₆

Computed Tomography, Abdomen and Pelvis;

without Contrast Material PA Medical Necessity Review

Radiology CT SCANS

74177

Computed Tomography, Abdomen and Pelvis; _{with Contrast Material(s)} PA Medical Necessity Review

Radiology CT SCANS

₇₄₁₇₈

Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(s) And Further Sections In One Or Both Body Regions PA Medical Necessity Review Radiology CT SCANS

74261

Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material PA Medical Necessity Review Radiology CT SCANS

74262

Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; With Contrast Material(s) Including Non‐Contrast Images, If Performed PA Medical Necessity Review Radiology CT SCANS

₇₄₂₆₃

Computed Tomographic (CT) Colonography, Screening, Including Image Postprocessing PA Medical Necessity Review Radiology MRI

75565

Cardiac MRI For Velocity Flow Mapping (List Separately In Addition To Code For Primary Procedure) Excluded from program Radiology CT SCANS

₇₅₅₇₁

CT Heart Without Contrast Material, With Quantitive Evaluation Of Coronary Calcium PA Medical Necessity Review

(15)

Medicaid,

CHP

Radiology _CT SCANS

₇₅₅₇₂

Cardiac CT For Morphology _{PA Medical Necessity Review}

Radiology _CT SCANS

₇₅₅₇₃

Cardiac CT For Congenital HD _{PA Medical Necessity Review}

Radiology _CT SCANS

₇₅₅₇₄

CT Angio Coronary Artery _{PA Medical Necessity Review}

Radiology CT SCANS

₇₅₆₃₅

CT Angiography Abdominal Aorta Aortic Aneurysm Excluded from program

Radiology 3DI

₇₆₃₇₆

3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Not Requiring Image Postprocessing On An Independent Workstation Excluded from program Radiology 3DI

₇₆₃₇₇

3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation Excluded from program Radiology NUCLEAR MED

78071

Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect) Excluded from program Radiology NUCLEAR MED

78072

Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect), And Concurrently Acquired Computed Tomography (CT) For Anatomical Localization Excluded from program

₇₈₄₅₁

MPI, Spect, Single Rest or Stress _{PA Medical Necessity Review}

₇₈₄₅₂

MPI, Spect, Multiple Rest or Stress _{PA Medical Necessity Review}

₇₈₄₅₃

MPI, Planar, Single Rest or Stress _{PA Medical Necessity Review}

₇₈₄₅₄

MPI, Planar, Multiple Rest or Stress _{Excluded from program}

(16)

Medicaid,

CHP

Radiology C‐CODES

_C8901

MRA without Contrast, Abdomen _{Excluded from program}

Radiology C‐CODES

_C8902

MRA with and without Contrast, Abdomen _{Excluded from program}

Radiology C‐CODES

_C8903

MRI with Contrast, Breast; Unilateral _{Excluded from program}

Radiology C‐CODES

_C8904

MRI without Contrast, Breast; Unilateral _{Excluded from program}

Radiology C‐CODES

C8905

MRI with and without Contrast, Breast; Unilateral Excluded from program

Radiology C‐CODES

_C8906

MRI with Contrast, Breast; Bilateral _{Excluded from program}

Radiology C‐CODES

_C8907

MRI without Contrast, Breast; Bilateral _{Excluded from program}

Radiology C‐CODES

C8908

MRI with and without Contrast, Breast; Bilateral Excluded from program

Radiology C‐CODES

C8909

MRA with Contrast, Chest (Excluding _Myocardium) Excluded from program

Radiology C‐CODES

C8910

MRA without Contrast, Chest (Excluding _Myocardium) Excluded from program

Radiology C‐CODES

C8911

MRA with and Without Contrast, Chest _{(Excluding Myocardium)} Excluded from program

Radiology C‐CODES

_C8912

MRA with Contrast, Lower Extremity _{Excluded from program}

Radiology C‐CODES

_C8913

MRA without Contrast, Lower Extremity _{Excluded from program}

Radiology C‐CODES

C8914

MRA with and Without Contrast, Lower _Extremity Excluded from program

Radiology C‐CODES

_C8918

MRA with Contrast, Pelvis _{Excluded from program}

Radiology C‐CODES

_C8919

MRA without Contrast, Pelvis _{Excluded from program}

(17)

Medicaid,

CHP

Radiology C‐CODES

C8921

Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; Complete Excluded from program Radiology C‐CODES

C8922

Transthoracic Echocardiography w/Contrast for Congenital Cardiac Anomalies; F/U or Limited Study Excluded from program Radiology C‐CODES

C8923

Transthoracic Echocardiography w/Contrast, Real‐ Time w/Image Documentation (2D), w or w/o M‐ Mode Recording; Complete Excluded from program Radiology C‐CODES

C8924

Transthoracic Echocardiography w/Contrast, Real‐ Time w/Image Documentation (2D), w or w/o M‐ Mode Recording; F/U Or Limited Study Excluded from program Radiology C‐CODES

C8928

Transthoracic Echocardiography with Contrast, Real Time w/Image Documentation (2D), w/ or w/o M‐Mode Recording, During Rest And Cardiovascular Stress Test, w/Interpretation and Report (Crosswalked To Either 93350 Or 93351) Excluded from program RADIOLOGY C‐CODES

C8929

Transthoracic Echocardiography with Contrast, or without Contrast Followed By with Contrast, Real‐ Time with Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, with Spectral Doppler Echocardiography, and with Color Flow Doppler Echocardiography Excluded from program

(18)

Medicaid,

CHP

RADIOLOGY C‐CODES

C8930

Transthoracic Echocardiography, with Contrast, or without Contrast Followed By with Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, with Interpretation and Report; Including Performance of Continuous Electrocardiographic Monitoring, with Physician Supervision Excluded from program RADIOLOGY C‐CODES

C8931

Magnetic Resonance Angiography with Contrast, _{Spinal Canal and Contents} Excluded from program

RADIOLOGY C‐CODES

C8932

Magnetic Resonance Angiography without _{Contrast, Spinal Canal and Contents} Excluded from program

RADIOLOGY C‐CODES

C8933

Magnetic Resonance Angiography without Contrast Followed by with Contrast, Spinal Canal and Contents Excluded from program RADIOLOGY C‐CODES

C8934

Magnetic Resonance Angiography with Contrast, _{Upper Extremity} Excluded from program

RADIOLOGY C‐CODES

C8935

Magnetic Resonance Angiography without _{Contrast, Upper Extremity} Excluded from program

RADIOLOGY C‐CODES

C8936

Magnetic Resonance Angiography without Contrast Followed by with Contrast, Upper Extremity Excluded from program Radiology G‐CODES

G0219

Pet Imaging Whole Body; Melanoma for Non‐ Covered Indications Investigational Radiology G‐CODES

G0235

Pet Imaging, Any Site, Not Otherwise Specified Redirect to valid code Radiology G‐CODES

G0252

Pet Imaging, Full and Partial‐Ring Pet Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer Redirect to valid code

₃₃₂₂₁

Insertion Of Pacemaker Pulse Generator Only;

(19)

Medicaid,

CHP

₃₃₂₂₄

Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, With Attachment To Previously Placed Pacemaker Or Implantable Defibrillator Pulse Generator (Including Revision Of Pocket, Removal, Insertion, And/Or Replacement Of Existing Generator) PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₂₅

Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, At Time Of Insertion Of Implantable Defibrillator Or Pacemaker Pulse Generator (Eg, For Upgrade To Dual Chamber System) (List Separately In

PA Medical Necessity Review Dual Chamber System) (List Separately In Addition To Code For Primary Procedure) Cardiology CARDIAC IMPLANTABLES

33227

Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₂₈

Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System PA Medical Necessity Review

33229

Removal Of Permanent Pacemaker Pulse _{Generator With Replacement Of Pacemaker} Pulse Generator; Multiple Lead System

PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₃₀

Insertion Of Implantable Defibrillator Pulse

Generator Only; With Existing Dual Leads PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₃₁

Generator Only; With Existing Multiple Leads PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

₃₃₂₄₀

Generator Only; With Existing Single Lead PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

33249

Insertion Or Replacement Of Permanent Implantable Defibrillator System With Transvenous Lead(s), Single Or Dual Chamber PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

33262

Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Single Lead System PA Medical Necessity Review

(20)

Medicaid,

CHP

33263

Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Dual Lead System PA Medical Necessity Review Cardiology CARDIAC IMPLANTABLES

33264

Removal of Implantable Defibrillator Pulse Generator with Replacement of Pacing Cardioverter‐Defibrillator Pulse Generator; Multiple Lead System PA Medical Necessity Review Insertion Or Replacement Of Permanent Subcutaneous Implantable Defibrillator System, with Subcutaneous Electrode, Including Defibrillation Threshold Evaluation, Indication of Cardiology CARDIAC IMPLANTABLES

₃₃₂₇₀

Arrythmia,Evaluation Of Sensing For Arrythmia

Termination, and Programming Or Reprogramming Of Sensing Or Therapeutic Parameters When Performed PA Medical Necessity Review Cardiology MRI

₇₅₅₅₇

Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material Excluded from program Cardiology MRI

₇₅₅₅₉

Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material; With Stress Imaging Excluded from program Cardiology MRI

₇₅₅₆₁

Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences Excluded from program Cardiology MRI

₇₅₅₆₃

Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences; With Stress Imaging Excluded from program Cardiology MRI

₇₅₅₆₅

Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Excluded from program

(21)

Medicaid,

CHP

Cardiology CT SCANS

₇₅₅₇₁

Computed Tomography, Heart, Without Contrast Material, With Quantitative Evaluation Of Coronary Calcium Excluded from program (Managed Under Radiology) Cardiology CT SCANS

₇₅₅₇₂

Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology (Including 3D Image Post processing, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) Excluded from program (Managed Under Radiology) Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology In The Setting Of Congenital Heart Cardiology CT SCANS

75573

p gy g g Disease (Including 3D Image Post processing, Assessment Of LV Cardiac Function, RV Structure And Function And Evaluation Of Venous Structures, If Performed) Excluded from program (Managed Under Radiology) Radiology CT SCANS

_S8032

Low‐Dose Computed Tomography for Lung Cancer Screening PA Medical Necessity Review Cardiology CT SCANS

₇₅₅₇₄

Computed Tomographic Angiography, Heart, Coronary Arteries And Bypass Grafts (When Present), With Contrast Material, Including 3D Image Post processing (Including Evaluation Of Cardiac Structure And Morphology, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) Excluded from program (Managed Under Radiology) Radiology S‐CODES

S8037

Magnetic Resonance Cholangiopancreatography _(MRCP) Redirect to valid code Radiology S‐CODES

S8042

Magnetic Resonance Imaging (MRI), Low‐Field Redirect to valid code

(22)

Medicaid,

CHP

Cardiology NUCLEAR STRESS

₇₈₄₅₁

Myocardial Perfusion Imaging, Tomographic (SPECT) Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic) Excluded from program (Managed Under Radiology) Radiology S‐CODES

S8080

Scintimammography (Radioimmunoscintigraphy of the Breast), Unilateral, Including Supply of Radiopharmaceutical Excluded from program

S8080

p g Cardiology NUCLEAR STRESS

78452

Myocardial Perfusion Imaging, Tomographic (SPECT) (Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest and/or Stress (Exercise Or Pharmacologic) and/or Redistribution and/or Rest Reinjection Excluded from program (Managed Under Radiology) Radiology S‐CODES

S8085

Fluorine‐18 Fluorodeomyglucose (F‐18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non‐Dedicated PET Scan) Investigational

(23)

Medicaid,

CHP

Cardiology NUCLEAR STRESS

₇₈₄₅₃

Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic) Excluded from program (Managed Under Radiology) Radiology S‐CODES

S8092

Electron Beam Computed Tomography (Also Known as Ultrafast CT, Cinet) Excluded from program Cardiology NUCLEAR STRESS

₇₈₄₅₄

Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest and/or Stress (Exercise Or Pharmacologic) and/or Redistribution and/or Rest Reinjection Excluded from program (Managed Under Radiology)

Cardiology PET

₇₈₄₅₉

PET Myocardial Imaging; Positron Emission Tomography (PET) Metabolic Evaluation

Excluded from program (Managed Under Radiology)

Cardiology NUCLEAR MED

₇₈₄₇₂

Gated Cardiac Radionuclide Angiography Excluded from program

₇₈₄₇₃

Gated Multiple Cardiac Radionuclide Angiography Excluded from program

₇₈₄₈₁

Planar First Pass Cardiac Radionuclide _Angiography Excluded from program

(Managed Under Radiology) Cardiology NUCLEAR MED

₇₈₄₈₃

Planar First Pass Multiple Cardiac Radionuclide

Angiography Excluded from program (Managed Under Radiology) Cardiology PET

₇₈₄₉₁

Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Single Study, Rest or Stress Excluded from program (Managed Under Radiology) Cardiology PET

78492

Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Multiple Studies, Rest and/or Stress Excluded from program (Managed Under Radiology)

(24)

Medicaid,

CHP

78494

SPECT Equilbrium Cardiac Radionuclide _Angiography Excluded from program

(Managed Under Radiology) Cardiology NUCLEAR MED

₇₈₄₉₆

SPECT EquilbriumMultiple Radionuclide

Angiography

Excluded from program (Managed Under Radiology) Cardiology ECHOCARDIOGRAPHY

₉₃₃₀₃

Transthoracic Echocardiography For Congenital

Cardiac Anomalies; Complete Excluded from program Cardiology ECHOCARDIOGRAPHY

₉₃₃₀₄

Transthoracic Echocardiography For Congenital Cardiac Anomalies; Follow‐Up Or Limited Study Excluded from program C di l ECHOCARDIOGRAPHY

93306

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, With E l d d f Cardiology ECHOCARDIOGRAPHY

93306

_{Spectral Doppler Echocardiography, And With}g, , p ,

Color Flow Doppler Echocardiography Excluded from program Cardiology ECHOCARDIOGRAPHY

₉₃₃₀₇

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐ Mode Recording; Complete Excluded from program Cardiology ECHOCARDIOGRAPHY

₉₃₃₀₈

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐ Mode Recording; Follow‐Up Or Limited Study Excluded from program Cardiology ECHOCARDIOGRAPHY

₉₃₃₂₀

Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Complete Excluded from program Cardiology ECHOCARDIOGRAPHY

93321

Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Follow‐ Up Or Limited Study Excluded from program Cardiology ECHOCARDIOGRAPHY

₉₃₃₂₅

Doppler Echocardiography Color Flow Velocity

Mapping Excluded from program Cardiology ECHO STRESS

93350

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), With Or Without M‐ Mode Recording, During Rest And Cardiovascular Stress Test, With Interpretation And Report Excluded from program

(25)

Medicaid,

CHP

Cardiology ECHO STRESS

₉₃₃₅₁

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, With Interpretation And Report; Including Performance Of Continuous Electrocardiographic Monitoring, With Supervision By A Physician Or Other Qualified Health Care Professional. Excluded from program Use of echocardiographic contrast agent during Cardiology ECHO STRESS

₉₃₃₅₂

Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) Excluded from program Cardiology CARDIAC CATH

93452

Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed Excluded from program Cardiology CARDIAC CATH

₉₃₄₅₃

Combined Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed Excluded from program Cardiology CARDIAC CATH

₉₃₄₅₄

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation Excluded from program Cardiology CARDIAC CATH

₉₃₄₅₅

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary Free Arterial Venous Grafts) Including

(26)

Medicaid,

CHP

Cardiology CARDIAC CATH

₉₃₄₅₆

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right Heart Catheterization Excluded from program Cardiology CARDIAC CATH

93457

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary, Free Arterial, Venous Grafts) Excluded from program

Including Intraprocedural Injection(s) For Bypass

₉₃₄₅₈

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed Excluded from program Cardiology CARDIAC CATH

₉₃₄₅₉

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass G ft( ) (I t l M F A t i l Excluded from program Cardiology CARDIAC CATH

₉₃₄₆₀

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including Excluded from program

(27)

Medicaid,

CHP

₉₃₄₆₁

Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass Graft(s) (Internal

Excluded from program

Radiation Therapy CPT

_0182T

High Dose Rate Electronic Brachytherapy, Per

Fraction PA Medical Necessity Review

_0190T

Placement Of Intraocular Radiation Source _Applicator PA Medical Necessity Review Radiology/Therapeutic‐General Classification

Radiation Therapy REV Code

₀₃₃₀

Radiology/Therapeutic ‐ General Classification PA Medical Necessity Review

₀₃₃₃

Radiology/Therapeutic ‐ Radiation Therapy PA Medical Necessity Review

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Radiology/Therapeutic ‐ Other PA Medical Necessity Review

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Therapeutic Radiopharmaceuticals PA Medical Necessity Review

₀₉₇₃

Professional Fees ‐ Radiology/Therapeutic PA Medical Necessity Review

₁₉₂₉₆

Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy On Date Separate From Partial Mastectomy PA Medical Necessity Review Radiation Therapy CPT

₁₉₂₉₇

Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy, Concurrent With Partial Mastectomy) PA Medical Necessity Review Radiation Therapy CPT

19298

Placement Of Radiation Therapy After loading Brachytherapy Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy PA Medical Necessity Review Radiation Therapy CPT

31643

Bronchoscopy (Rigid Or Flexible), With Placement Of Catheter For Intracavitary Radioelement Application PA Medical Necessity Review

(28)

Medicaid,

CHP

₃₂₅₅₃

Placement Of Interstitial Device For Radiation Therapy Guidance, Percutaneous, Intra‐Thoracic, Single Or Multiple PA Medical Necessity Review Radiation Therapy CPT

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Placement Of Needles, Catheters, And Other Devices Into The Head and/or Neck Region PA Medical Necessity Review Radiation Therapy CPT

₄₃₂₄₁

Upper Gastrointestinal Endoscopy Including Esophagus, Stomach And Either The Duodenum and/or Jejunum As Appropriate; W/ Transendoscopic Intraluminal Tube Or Catheter Placement PA Medical Necessity Review Placement Of Interstitial Device(s) For Radiation Therapy Guidance, Open, Intra‐Abdominal, Intra‐ Radiation Therapy CPT

₄₉₄₁₁

py , p , , Pelvic and/or Retroperitoneum, Including Image Guidance, Single Or Multiple PA Medical Necessity Review Radiation Therapy CPT

₄₉₄₁₂

Placement Of Interstitial Device(s) For Radiation Therapy Guidance (Eg, Fiducial Markers, Dosimeter), Open, Intra‐Abdominal, Intrapelvic, and/or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To Code For Primary Procedure) PA Medical Necessity Review Radiation Therapy CPT

₅₅₈₇₅

Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application, With Or Out Cytosocopy PA Medical Necessity Review

55876

Fiducial Marker Placement In The Prostate PA Medical Necessity Review

55920

Placement Of Needles, Catheters, Or Other Device(s) Into The Head and/or Neck Region (Percutaneous, Transoral, Or Transnasal) For Subsequent Interstitial Radioelement Application PA Medical Necessity Review

(29)

Medicaid,

CHP

₅₇₁₅₆

Insertion Of A Vaginal Radiation After Loading Apparatus For Clinical Brachytherapy PA Medical Necessity Review Radiation Therapy CPT

₅₈₃₄₆

Insertion Of Heyman Capsulesfor Clinical Brachytherapy PA Medical Necessity Review Radiation Therapy CPT

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US Transrectal Prostate Volume Study For Brachytherapy PA Medical Necessity Review Radiation Therapy CPT

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Ultrasound Guidance For Interstitial Radioelement Application PA Medical Necessity Review Radiation Therapy CPT

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Computed Tomography Guidance For Stereotactic Localization PA Medical Necessity Review R di ti Th CPT

77014

CT Guidance For Placement Of Radiation Therapy PA M di l N it R i

77014

_Fields py PA Medical Necessity Review

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Therapeutic Radiology Treatment Planning;

Simple PA Medical Necessity Review

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Therapeutic Radiology Treatment Planning;

Intermediate PA Medical Necessity Review

77263

Therapeutic Radiology Treatment Planning; _Complex PA Medical Necessity Review

₇₇₂₈₀

Therapeutic Radiology Simulation; Simple PA Medical Necessity Review

₇₇₂₈₅

Therapeutic Radiology Simulation; Intermediate PA Medical Necessity Review

₇₇₂₉₀

Therapeutic Radiology Simulation; Complex PA Medical Necessity Review

₇₇₂₉₃

Respiratory Motion Management Simulation (List Separately In Addition To Code For Primary Procedure) PA Medical Necessity Review Radiation Therapy CPT

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3‐Dimensional Radiotherapy Plan, Including Dose‐ Volume Histograms PA Medical Necessity Review Radiation Therapy CPT

₇₇₂₉₉

Unlisted Procedure; Therapeutic Radiology Treatment Planning PA Medical Necessity Review

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Basic Radiation Dosimetry PA Medical Necessity Review

₇₇₃₀₁

IMRT Planning PA Medical Necessity Review

77306

Teletherapy Isodose Plan; Simple (1 Or 2 Unmodified Ports Directed To A Single Area Of

YourCare Health Plan 2015 CPT Code/Prior Authorization List

Medicaid,

CHP

70336

70450

70470

70480

70481

70482

70486

70487

70488

70488

70490

70491

70492

70496

70498

70540

70542

70543

70544

70545

70546

70547

70548

70549

70551

70552

Medicaid,

CHP

70554

70555

71250

71260

71270

71270

71275

71550

71551

71552

71555

72126

72127

72128

72129

72130

72132

72133

72141

72142

72146

72147

Medicaid,

CHP

72149

72156

72157

72158

72159

72191

72192

72193

72194

72194

72195

72196

72197

72198

73200

73201

73202

73206

73218

73219

73220

73221

73222

73223

73225

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