Purpose
The intent of this document is to communicate Commercial Product coverage determinations for services identified through the Annual Code Update process. The procedure codes that represent these services will become effective on 1/1/2021, unless otherwise noted.
For more information related to these services, please refer to specific policies when applicable.
Coverage Statement
As a result of the Annual Code Update process, the following services have been reviewed; coverage determinations made by the Company are identified below. The procedure codes that represent these services will be effective on 1/1/2021, unless otherwise noted.
Coding
Inclusion of a code in this communication does not imply reimbursement. Medical Necessity, eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
ELIGIBLE SERVICES
0001A
0002A
0011A
0012A
0230U
0231U
0232U
0233U
0234U
0235U
0236U
0237U
0238U
0239U
32408
33741
33745
33746
33995
33997
69705
69706
71271
76145
80143
80151
80161
80167
80179
80181
80189
80193
80204
80210
81168
81191
81192
81193
81194
81278
81279
81338
81339
81347
81348
81351
81352
81353
81357
81360
81419
81546
82077
82681
87428
90377
92229
92517
92518
92519
92650
92651
92652
92653
93241
93242
93243
93244
93245
93246
93247
93248
94619
A9591
C1052
C9068
C9069
C9070
C9072
C9073
C9770
G0088
G0089
G0090
G2213
G2250
G2251
G2252
J0693
J1823
J7212
J7352
J9144
J9223
J9281
J9316
J9317
M0239
M0243
Q5122
S0013
U0005
NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
99417
99439
G2212
G2214
NOT ELIGIBLE FOR REIMBURSEMENT
9130091301G2215G2216Q0239Q0243
EXPERIMENTAL/INVESTIGATIONAL SERVICES
0017M
0620T
0621T
0622T
0623T
0624T
0625T
0626T
0627T
0628T
0629T
0630T
0631T
0632T
0633T
0634T
0635T
0636T
0637T
0638T
0639T
0227U
0228U
0229U
30468
55880
57465
81513
81514
81529
81554
C1062
C1825
C9071
C9771
C9772
C9773
C9774
C9775
BENEFIT EXCLUSION
D0604
D0605
D0701
D0702
D0703
D0704
D0705
D0706
D0707
D0708
D0709
D1321
D1355
D2928
D3471
D3472
D3473
D3501
D3502
D3503
D5995
D5996
D6191
D6192
D7961
D7962
D7993
D7994
*The following codes have varying effective dates and became effective prior to 1/1/2021.
Codes Q0239 and M0239 are effective for dates of service 11/9/2020 forward.
Code 87428 is effective for dates of service 11/10/2020 forward.
Codes Q0243 and M0243 are effective for dates of service 11/21/2020 forward.
Codes 0001A, 0002A and 91300 are effective for dates of service 12/11/2020 forward.
Codes 0011A, 0012A and 91301 are effective for dates of service 12/18/2020 forward.
