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Date
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Date
Title
CPT Codes Covered in Policy
L33392 10/01/2015 08/02/2018 Category III CPT® Codes 0042T 0054T 0055T 0058T 0071T 0072T 0075T 0076T 0085T 0095T 0098T 0100T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0159T 0163T 0164T 0165T 0174T 0175T 0184T 0188T 0189T 0190T 0195T 0196T 0198T 0200T 0201T 0202T 0205T 0206T 0207T and more.....
L33394 10/01/2015 12/01/2017 Drugs and Biologicals, Coverage of, for Label and Off-Label Uses XX000
L33396 10/01/2015 10/01/2015 Posterior Tibial Nerve Stimulation for Voiding Dysfunction 64566
L33398 10/01/2015 06/15/2018 Transcranial Magnetic Stimulation 90867 90868 90869
L33399 10/01/2015 10/01/2015 EEG – 24 Hour Monitoring 95950 95951 95953 95956
L33557 10/01/2015 10/01/2018 Cardiac Catheterization and Coronary Angiography 36140 36200 36215 36216 36217 36218 36245 36246 36247 36248 36251 36252 36253 36254 75625 75630 75705 75710 75716 92978 92979 93451 93452 93453 93454 93455 93456 93457 93458 93459 93460 93461 93462 93463 93464 93505 93530 93531 93532 93533 and more.....
L33558 10/01/2015 11/01/2016 Cataract Extraction 66840 66850 66852 66920 66930 66940 66982 66983 66984
L33559 10/01/2015 01/01/2018 Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 0501T 0502T 0503T 0504T 75571 75572 75573 75574
L33560 10/01/2015 10/01/2017 Cardiovascular Nuclear Medicine 78451 78452 78453 78454 78466 78468 78469 78472 78473 78481 78483 78494 78496 A9500 A9501 A9502 A9505 A9512 A9520 A9538 A9560 Q9969
L33562 10/01/2015 10/01/2018 Computed Tomographic (CT) Colonography for Diagnostic Uses 74261 74262
L33563 10/01/2015 10/01/2018 Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures 10060 10061 10080 10081 10140 10160 10180
L33567 10/01/2015 10/01/2017 Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 92225 92226 92227 92228 92250
L33569 10/01/2015 10/01/2015 Vertebroplasty and Vertebral Augmentation (Percutaneous) 22510 22511 22512 22513 22514 22515 76380
L33573 10/01/2015 01/01/2018 B-type Natriuretic Peptide (BNP) Testing 83880
L33574 10/01/2015 10/01/2018 Visual Fields Testing 92081 92082 92083
L33575 10/01/2015 01/01/2018 Varicose Veins of the Lower Extremity, Treatment of 36465 36466 36468 36470 36471 36473 36474 36475 36476 36478 36479 36482 36483 37700 37718 37722 37735 37760 37761 37765 37766 37780 37799
L33576 10/01/2015 10/01/2018 Urodynamics 51725 51726 51727 51728 51729 51736 51741 51792 51797
L33577 10/01/2015 10/01/2018 Transthoracic Echocardiography (TTE) 76376 76377 93303 93304 93306 93307 93308 93320 93321 93325 93350 93351 93352 A9700 C8921 C8922 C8923 C8924 C8928 C8929 C8930 J0153 J0280 J0461 J1245 J1250 J2785 Q9955 Q9956 Q9957
L33578 10/01/2015 10/01/2018 Transrectal Ultrasound 76872 76873
L33579 10/01/2015 10/01/2018 Transesophageal Echocardiography (TEE) 76376 76377 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 C8925 C8926 C8927
L33580 10/01/2015 01/01/2018 Speech-Language Pathology 31579 92507 92508 92521 92522 92523 92524 92597 92607 92608 92609 92626 92627 96105 96110 96111 97533 G0451 G0515
L33584 10/01/2015 11/01/2016 Implantable Miniature Telescope (IMT) 0308T C1840
L33585 10/01/2015 10/01/2017 Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography 19030 76641 76642 77053 77054 77058 77059 C8903 C8904 C8905 C8906 C8907 C8908
L33591 10/01/2015 01/01/2018 RAST Type Tests 86001 86003 86005 86008
L33613 10/01/2015 05/15/2017 Chiropractic Services 98940 98941 98942
L33614 10/01/2015 04/01/2016 Debridement Services 11000 11001 11042 11043 11044 11045 11046 11047 97597 97598
L33616 10/01/2015 11/01/2016 Osteopathic Manipulative Treatment 98925 98926 98927 98928 98929
L33619 10/01/2015 10/01/2016 Nonvascular Extremity Ultrasound 76881 76882
L33621 10/01/2015 10/01/2015 Ophthalmic Biometry for Intraocular Lens Power Calculation 76519 92136
L33622 10/01/2015 10/01/2018 Pain Management 20526 20550 20551 20552 20553 20612 27096 28899 G0260
L33623 10/01/2015 01/01/2018 Percutaneous Coronary Intervention 92920 92921 92924 92925 92928 92929 92933 92934 92937 92938 92941 92943 92944 92973 92975 92978 92979 93571 93572 C9600 C9601 C9602 C9603 C9604 C9605 C9606 C9607 C9608
L33624 10/01/2015 10/01/2018 Psychiatric Inpatient Hospitalization XX000
L33626 10/01/2015 12/01/2018 Psychiatric Partial Hospitalization Programs 90785 90791 90792 90832 90833 90834 90836 90837 90838 90846 90847 90899 96101 96102 96103 96116 96118 96119 96120 G0129 G0176 G0177 G0410 G0411
L33627 10/01/2015 10/01/2018 Non-Invasive Vascular Studies 93880 93882 93886 93888 93890 93892 93893 93922 93923 93924 93925 93926 93930 93931 93970 93970 93971 93971 93975 93976 93978 93979 93990 G0365
L33628 10/01/2015 01/01/2018 Panretinal (Scatter) Laser Photocoagulation 67228
L33629 10/01/2015 10/01/2018 Non-covered Services 0003U 01470 28035 53860 64702 64704 64708 64712 64714 64722 64726 64727 71045 71046 71047 71048 75571 81500 81503 82172 82777 83006 83719 84066 84999 86152 86153 92700 93000 93005 93010 93040 93041 93042 94014 94015 94016
L33630 10/01/2015 08/01/2017 Corneal Pachymetry 76514 92499
L33631 10/01/2015 10/01/2018 Outpatient Physical and Occupational Therapy Services 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29240 29260 29280 29345 29355 29365 29405 29425 29445 29505 29515 29520 29530 29540 29550 29580 29799 90901 90911 95831 95832 95833 95834 95851 95852 95992 96125 97010 97012 97016 and more.....
L33632 10/01/2015 10/01/2018 Psychiatry and Psychology Services 90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90849 90853 90863 90865 90870 90880 90885 90887 90889 90899 96101 96102 96103 96105 96110 96111 96116 96118 96119 96120 G0451
L33633 10/01/2015 10/01/2018 Magnetic Resonance Angiography (MRA) 70544 70545 70546 70547 70548 70549 71555 72159 72198 73225 73725 74185 C8900 C8901 C8902 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936
L33636 10/01/2015 10/01/2017 Routine Foot Care and Debridement of Nails 11055 11056 11057 11719 11720 11721 G0127
L33646 10/01/2015 10/01/2018 Botulinum Toxins 43201 43236 46505 52287 64611 64612 64615 64616 64617 64642 64643 64644 64645 64646 64647 64650 64653 67345 J0585 J0586 J0587 J0588
L34380 10/01/2015 01/01/2018 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 92132 92133 92134
L35000 10/01/2015 10/01/2018 Molecular Pathology Procedures 81105 81106 81107 81108 81109 81110 81111 81112 81120 81121 81161 81162 81170 81175 81176 81200 81201 81202 81203 81205 81206 81207 81208 81209 81210 81211 81212 81213 81214 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 and more.....
L35001 10/01/2015 10/01/2015 Reduction Mammaplasty 19316 19318
L35028 10/01/2015 01/01/2017 Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency 37248 37249
L35074 10/01/2015 01/01/2017 Heavy Metal Testing 82108 82175 82300 82495 82525 83015 83018 83655 83785 83825 83885 84255 84285 84630 84999
L35075 10/01/2015 10/01/2018 Proton Beam Therapy 77520 77522 77523 77525
L35076 10/01/2015 10/01/2018 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 77371 77372 77373 77373 77432 77435 77435 G0339 G0339 G0340 G0340
L35080 10/01/2015 12/01/2017 Select Minimally Invasive GERD Procedures 43210 43257 43284 43499 43999 49999
L35098 10/01/2015 10/01/2018 Nerve Conduction Studies and Electromyography 51785 92265 95860 95861 95863 95864 95865 95866 95867 95868 95869 95870 95872 95873 95874 95885 95886 95887 95905 95907 95908 95909 95910 95911 95912 95913 95933 95937 95999 G0255
L35936 10/01/2015 10/01/2015 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 64490 64491 64492 64493 64494 64495 64633 64634 64635 64636
L35937 10/01/2015 10/01/2017 Lumbar Epidural Injections 62322 62323 62326 62327 64483 64484
L36037 12/01/2015 10/01/2018 Urine Drug Testing 80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L36039 12/01/2015 12/01/2015 Total Joint Arthroplasty 27130 27132 27134 27137 27138 27445 27447 27486 27487
L36236 10/01/2015 10/01/2017 Autonomic Function Testing 95921 95922 95923 95924 95943
L36376 04/01/2016 Genomic Sequence Analysis Panels in the Treatment of Non-Small Cell Lung Cancer 81445
L36406 04/01/2016 Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 27279
L36831 03/16/2017 02/01/2018 Visual Electrophysiology Testing 0333T 0464T 92275 95930
L36850 05/01/2017 10/01/2018 Peripheral Nerve Blocks 64400 64402 64405 64413 64415 64416 64417 64418 64420 64421 64425 64430 64445 64446 64447 64448 64449 64450 64455
L37244 12/01/2017 11/08/2018 Micro-Invasive Glaucoma Surgery (MIGS) 0191T 0376T 0449T 0450T 0474T
L37421 04/01/2018 04/01/2018 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 0398T
L37485 07/02/2018 10/15/2018 Prostate Rectal Spacers 55874
L37535 04/01/2018 10/01/2018 Vitamin D Assay Testing 82306 82652
L37606 08/01/2018 08/01/2018 Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases 81450
L37733 12/01/2018 Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis 0005U 81479 81539 84153 84154 86316
L37808 12/01/2018 Water Vapor Thermal Therapy for LUTS/BPH 53899 C9748



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