Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
   


Policy #
Policy Bulletin Title
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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
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12.00.01f
Acupuncture (Independence)
12.04.04
Acute Care Facility Inpatient Transfers
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08.01.11d
Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69a
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22c
Alemtuzumab (Lemtrada™)
08.00.72g
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52g
Always Bundled Procedure Codes
07.02.09e
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21c
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
06.03.04n
Apheresis Therapy
11.08.05g
Application and Removal of Tattoos
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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11.05.16g
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19l
Artificial Intervertebral Disc Insertion
08.01.35a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06f
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
07.03.23b
Autonomic Nervous System Testing
11.16.06h
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02r
Bariatric Surgery
08.01.03c
Belatacept (Nulojix®)
08.00.99b
Belimumab (Benlysta®) for intravenous use
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08.00.66k
Bevacizumab (Avastin®) and related biosimilars
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00.10.39j
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
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00.10.38
Billing Requirements for Multiple Births for Professional Providers
07.00.01h
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
08.01.21c
Blinatumomab (Blincyto®)
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11.01.06d
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
09.00.04i
Bone Mineral Density (BMD) Testing
08.00.73k
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26u
Botulinum Toxin Agents
09.00.10y
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76b
Breast Pumps
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08.01.13c
Brentuximab Vedotin (Adcetris®)
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96d
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
00.01.59e
Care Management and Care Planning Services
08.01.05e
Carfilzomib (Kyprolis™)
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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11.01.07d
Cataract Surgery
11.02.06l
Catheter Ablation of Cardiac Arrhythmias
08.01.39b
Cerliponase alfa (Brineura™)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67k
Cetuximab (Erbitux®)
11.08.08g
Chemical Peels
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08.01.43d
Chimeric Antigen Receptor (CAR) Therapy
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10.02.02i
Chiropractic Spinal and Extraspinal Manipulation Therapy
08.00.92x
Coagulation Factors
11.01.02n
Cochlear Implant
11.03.12q
Colorectal Cancer Screening
12.00.03f
Complementary and Integrative Health Services
07.06.01b
Complete Decongestive Therapy (CDT)
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
05.00.37f
Compression Garments
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
06.00.01e
Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
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07.13.07j
Corneal Pachymetry Using Ultrasound
12.01.03
Cosmetic Procedures
08.01.08c
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.25g
Cranial Remolding Orthoses (Helmets)
00.10.03i
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29d
Daratumumab (Darzalex™)
10.00.02b
Day Rehabilitation
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11.08.17h
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09l
Denervation of the Spinal Nerves for Chronic Pain
04.00.03a
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
08.01.24
Deoxycholic Acid (Kybella™)
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00.03.02y
Diagnostic Radiology Services Included in Capitation
00.09.01e
Direct Access Obstetrics/Gynecology (OB/GYN)
08.00.49d
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Probuphine Implant, Vivitrol Injection)
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05.00.21t
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
09.00.11c
Echocardiography Contrast Agents
08.00.84d
Eculizumab (Soliris®)
08.01.42a
Edaravone (Radicava™)
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11.06.02i
Elective Abortion
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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07.07.07f
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
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07.03.09o
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21j
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54
Emapalumab-lzsg (Gamifant®)
11.06.05e
Endometrial Ablation
11.02.10m
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
08.00.51i
Enzyme Replacement for the Treatment of Gaucher's Disease
08.00.70d
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, Mepsevii™, etc.)
11.15.23g
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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05.00.05k
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.75m
Erythropoiesis-Stimulating Agents (ESAs)
07.02.22
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07r
Evaluation and Management of Autism Spectrum Disorders (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
03.02.13f
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
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06.02.52l
eviCore Lab Management Program (Independence)
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12.01.01ar
Experimental/Investigational Services
07.02.05j
External Counterpulsation (ECP)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
00.01.19d
Facility Reporting of Observation Services
07.05.08a
Fecal Microbiota Transplantation (FMT)
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
11.00.03j
Fetal Surgery
09.00.36k
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
05.00.04d
Food and Drug Administration (FDA) Approval of Medical Devices
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05.00.35e
Foot Orthotics and Other Podiatric Appliances
11.03.05c
Frenectomy or Frenotomy for Ankylogossia (Tongue-Tie)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (Independence Administrators)
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06.02.06p
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (Independence Administrators)
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06.02.35t
Genetic Testing (Independence Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.33a
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
06.02.50
GPS Cancer™ Testing by NantHealth
12.04.02h
Ground Ambulance Transport Services (Emergency and Nonemergency)
00.05.01e
Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program
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11.08.01f
Hair Transplants and Cranial Prostheses (Wigs)
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11.07.01s
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
05.00.14j
High-Frequency Chest Wall Oscillation Devices
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09.00.46v
High-Technology Radiology Services (Independence)
09.00.13c
High Osmolar Contrast Agents
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08.00.97h
Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
02.01.01d
Home Health Care Services
05.00.58l
Home Oxygen Therapy
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05.00.26g
Home Prothrombin Time Monitoring
05.00.65e
Home Uterine Activity Monitoring (HUAM) Devices
02.02.01g
Hospice Care
05.00.56i
Hospital Beds and Accessories
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)
00.10.37b
Humanitarian Use Devices (HUD) and the Humanitarian Device Exemption (HDE) Process
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
08.01.46a
ibalizumab-uiyk (Trogarzo™)
06.02.37a
Immune Cell Function Assay
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08.00.13t
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.01.04t
Immunizations
11.16.08b
Implantable Steroid-Eluting Sinus Stents
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
06.02.26d
In Vitro Allergy Testing
06.02.14h
In Vitro Chemosensitivity and Chemoresistance Assays
07.00.05g
In Vivo Allergy Sensitivity Testing
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08.00.34l
Infliximab and Related Biosimilars
05.00.62h
Injectable Dermal Fillers
00.01.47c
Inpatient Hospital Readmission
11.15.03j
Insertion of Implantable Infusion Pumps
03.12.04c
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
07.13.12d
Instrument-Based Vision Screening
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05.00.79a
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
08.01.23e
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
11.14.07t
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
07.03.14n
Intraoperative Neurophysiological Monitoring (INM)
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07.00.02i
Intravenous Chelation Therapy
00.01.45
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
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08.00.74l
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
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08.01.01h
Ipilimumab (Yervoy®)
11.04.01c
Islet Cell Transplantation
05.00.47n
Knee Orthoses
11.06.09d
Labiaplasty
07.03.24
Laboratory-Based Vestibular Function Testing
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00.03.07v
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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08.01.40a
Lanreotide (Somatuline® Depot)
11.08.03j
Lipectomy and Liposuction
07.00.14f
Low-level Laser Therapy (LLLT)
09.00.31d
Low Osmolar Contrast Agents
Show details for
05.00.59i
Lower Limb Prostheses
06.02.01i
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
11.15.13d
Lysis of Epidural Adhesions
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
09.00.45g
Magnetic Resonance Imaging (MRI) Contrast Agents
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
11.14.24b
Manipulation Under Anesthesia
05.00.12g
Manual Wheelchairs
00.01.48c
Marijuana for Medical Use
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
06.02.39b
Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
07.08.03d
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.03.03f
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
12.01.02
Medical Necessity
00.10.31c
Medical Team Conferences
Show details for
11.14.03f
Meniscal Allograft Transplantation
11.14.01g
Mentoplasty or Genioplasty
11.14.21g
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
11.15.24a
Migraine Deactivation Surgery
03.00.15n
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
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03.00.06p
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.05i
Modifier 50: Bilateral Procedure
03.00.32
Modifier 52 Reduced Services
03.00.33
Modifier 53: Discontinued Procedure
03.00.16n
Modifier 57: Decision for Surgery
00.10.11k
Modifier 62: Two Surgeons
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00.10.17h
Modifier 66: Surgical Team
03.00.02a
Modifier 76: Repeat Procedure by Same Physician
03.00.11a
Modifier 77: Repeat Procedure by Another Physician
03.00.12e
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
03.00.28l
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
03.00.20h
Modifiers 26 (Professional Component) and TC (Technical Component)
00.10.18j
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
03.00.31e
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.08d
Modifiers XE, XS, XP, XU, 59
08.01.52
Mogamulizumab-kpkc (Poteligeo®)
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11.08.23j
Mohs' Micrographic Surgery
08.01.53
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
06.02.32d
Multigene Expression Assays for Predicting Recurrence in Colon Cancer (Independence Administrators)
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00.01.60c
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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11.00.10u
Multiple Surgical Reduction Guidelines (Independence)
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00.01.66b
Musculoskeletal Services (Independence)
08.00.64f
Natalizumab (Tysabri®)
00.01.56a
National Correct Coding Initiative (NCCI) Code Pair Edits
05.00.15p
Nebulizers and Inhalation Solutions
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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07.03.18n
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
06.02.38d
Nerve Fiber Density Testing
05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
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00.01.44h
Never Events and Preventable Adverse Events
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.10.05k
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.03.25
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
06.02.47b
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA (Independence Administrators)
05.00.30l
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
06.02.56a
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
11.15.19e
Nucleoplasty
08.01.36d
Nusinersen (Spinraza®)
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
00.01.24g
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.03.10e
Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
08.01.38b
Ocrelizumab (Ocrevus™)
Show details for
08.01.10d
Octreotide acetate (Sandostatin® LAR Depot)
08.00.88e
Ofatumumab (Arzerra™)
08.00.15d
Off-label Coverage for Prescription Drugs and/or Biologics
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08.00.55h
Omalizumab (Xolair®)
11.14.08d
Orthognathic Surgery
07.13.01g
Orthoptic/Pleoptic Training
11.14.12e
Osteochondral Allograft Transplantation
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
Show details for
05.00.50k
Ostomy Supplies
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
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12.05.01i
Outpatient Diabetes Education and Self-Management Training
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00.03.03g
Outpatient Short-Term Rehabilitation Services Included in Capitation
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
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08.00.90i
Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound) / (Abraxane® for Injectable Suspension)
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
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07.13.08e
Partial Coherence Interferometry
06.02.36b
PathFinderTG® (Independence Administrators)
05.00.42g
Patient Lifts
08.01.50a
Patisiran (Onpattro™)
10.00.03
Pediatric Intensive Day Feeding Program
08.01.26
Pegademase bovine (Adagen®)
Show details for
08.01.32
Pegfilgrastim (Neulasta®)
Show details for
08.01.02d
Pegloticase (Krystexxa®)
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
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08.00.87e
Pemetrexed (Alimta®)
Show details for
11.02.27
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
11.15.15g
Percutaneous Discectomy
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
11.15.22d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.02.26a
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.14.10q
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
08.00.95d
Personalized Vaccines (e.g. Provenge®)
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08.01.07e
Pertuzumab (Perjeta®)
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06.02.30e
Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.18k
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (Independence Administrators)
11.05.08d
Photocoagulation of Macular Drusen
Show details for
07.07.03l
Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
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00.03.06e
Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
10.03.01j
Physical Medicine, Rehabilitation, and Habilitation Services
00.10.16d
Physician/Nonphysician Standby Services
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05.00.01l
Pneumatic Compression Therapy Devices
09.00.51a
Positron Emission Mammography (PEM)
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
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00.01.25ar
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
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08.00.83g
Pralatrexate (Folotyn®) for Injection
06.02.24j
Preimplantation Genetic Testing (Independence Administrators)
01.00.08c
Preoperative Consultations Performed by Providers in Anesthesia Specialties
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07.13.13c
Prescription Lenses and Visual Devices
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05.00.60g
Pressure-Reducing Support Surfaces
06.02.44h
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
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00.06.02x
Preventive Care Services (Independence)
02.01.02c
Private Duty Nursing
11.08.29e
Procedures for the Treatment of Acne
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
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08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
11.08.19m
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
09.00.49k
Proton Beam Radiation Therapy
10.04.01k
Pulmonary Rehabilitation
05.00.31e
Pulse Oximetry Devices in the Home Setting
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09.00.56h
Radiation Therapy Services (Independence)
09.00.48f
Radioembolization for Primary and Metastatic Tumors of the Liver (Independence Administrators)
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
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00.10.36p
Radiologic Guidance of a Procedure
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
08.01.25c
Ramucirumab (Cyramza®)
11.08.15u
Reconstructive Breast Surgery
11.08.02h
Reduction Mammoplasty
11.05.01e
Refractive Keratoplasty
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
00.01.18c
Reimbursement for Associated Services Performed in Conjunction with Dental Care
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00.01.61
Reimbursement for Components of Comprehensive Laboratory Panels
09.00.32t
Reimbursement for Diagnostic and Therapeutic Radiopharmaceutical Agents for Professional Providers
00.10.40b
Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)
07.00.15l
Reimbursement for the Administration of Immunizations
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11.08.14j
Removal of Breast Implants
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
05.00.45k
Repair or Replacement of an External Prosthetic Device
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00.01.14q
Reporting and Documentation Requirements for Anesthesia Services
00.01.49c
Reporting Requirements for Drugs and Biologics
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
11.00.01e
Revision of a Previous Cosmetic Procedure
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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08.00.50r
Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
11.00.18
Robotic-Assisted Surgery
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
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07.07.01n
Routine Foot Care for Certain Medical Conditions
11.17.04s
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
11.11.06h
Saturation Needle Biopsy of the Prostate
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
11.08.25m
Scar Revision
09.00.40d
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
05.00.43f
Seat Lift Mechanisms
08.01.28c
Sebelipase alfa (Kanuma®)
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
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08.00.78aa
Self-Administered Drugs
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11.07.02i
Sentinel Lymph Node Biopsy
11.16.01h
Septoplasty, Rhinoplasty, and Septorhinoplasty
06.02.17e
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
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00.10.01aa
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
08.01.19e
Siltuximab (Sylvant®)
07.03.05u
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
07.11.01c
Smell and Taste Dysfunction Testing
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
05.00.32i
Speech and Non-Speech Generating Devices
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10.06.01k
Speech Therapy
11.15.01u
Spinal Cord and Dorsal Root Ganglion Stimulation
11.14.22d
Spinal Decompression with Interspinous and Interlaminar Devices
11.14.29c
Spinal Discectomy
11.14.27c
Spinal Fusion
11.14.28b
Spinal Laminectomy
05.00.71c
Standing Frames
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00.01.41b
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
07.07.09f
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
11.08.12h
Surgery for Gynecomastia
11.17.06l
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
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11.05.07d
Surgical Correction of Strabismus
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
11.14.26a
Surgical Treatments of Athletic Pubalgia
08.01.27d
Talimogene laherparepvec (Imlygic™)
00.10.41d
Telemedicine for Primary Care Services (Independence)
06.02.51c
Testing Serum Vitamin D Levels
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
09.00.23c
Therapeutic Radiology Port Films
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05.00.11i
Therapeutic Shoes and Orthopedic Shoes
08.01.48a
Tildrakizumab-asmn (Ilumya™)
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08.00.85g
Tocilizumab (Actemra®) for Intravenous Infusion
07.00.09d
Topical Oxygenation
11.02.19f
Total Artificial Hearts (TAHs)
08.00.17g
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
07.05.06f
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
11.02.25f
Transcatheter Cardiac Valve Procedures
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
07.03.22c
Transcranial Magnetic Stimulation (TMS)
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05.00.74c
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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08.00.33l
Trastuzumab (Herceptin®) and Related Biosimilars
11.09.02f
Treatment of Gender Dysphoria
11.00.02f
Treatment of Medical and Surgical Complications
11.00.06j
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
08.00.25j
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
11.00.14e
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.02.01q
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
08.00.57m
Treatments for Complex Regional Pain Syndrome (CRPS)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
11.14.02m
Trigger Point Injections
07.03.26
Tumor Treating Fields
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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05.00.72e
Upper Limb Prostheses
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11.00.11k
Use of an Operating Microscope During a Surgical Procedure
08.00.82j
Ustekinumab (Stelara®)
11.06.04j
Uterine Artery Embolization
11.15.16n
Vagus Nerve Stimulation (VNS)
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
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08.01.18c
Vedolizumab (Entyvio®)
11.02.16r
Ventricular Assist Devices (VADs)
06.02.49b
VeriStrat® Testing for Targeted Therapy in Non-Small Cell Lung Cancer
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)
05.00.55i
Wheelchair Cushions and Seating
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05.00.67o
Wheelchair Options and Accessories
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
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11.08.20s
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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00.03.09d
X-rays Associated with Fractures in the Office Setting

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