The intent of this document is to communicate Commercial Product coverage determinations for services identified through the Quarterly Code Update process. The procedure codes that represent these services will become effective on 04/01/2025, unless otherwise noted.
For more information related to these services, please refer to specific policies when applicable.
Inclusion of a code in this document does not imply reimbursement. Medical Necessity, eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
ELIGIBLE SERVICES
0532U
0536U
0538U
0543U
A2030
A2031
A2032
A2033
A2034
A2035
A6515
A6516
A6517
A6518
A6519
A6611
A9154
C9300
C9301
C9302
C9303
C9304
E1032
E1033
E1034
G0567
J0281
J1072
J1271
J1299
J1308
J1808
J1938
J2351
J2428
J2804
J2865
J7521
J9024
J9161
L0720
L1933
L1952
L6028
L6029
L6030
L6031
L6032
L6033
L6037
L6700
L7406
Q2057
Q4354
Q4355
Q4356
Q4357
Q4358
Q4359
Q4361
Q4362
Q4363
Q4364
Q4365
Q4366
Q4367
Q5147
Q5148
Q5149
Q5150
Q5152
Q9999
* HCPCS code G0567 has a retro-effective date, 06/27/2024.
EXPERIMENTAL/INVESTIGATIONAL SERVICE
0531U
0533U
0534U
0535U
0537U
0539U
0540U
0541U
0542U
0544U
0545U
0546U
0547U
0548U
0549U
0550U
0551U
C8004
C8005
E0201
E1832
L5827
Q4360
S4024
BENEFIT EXCLUSION
E1022
E1023
NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
A9611
