Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

Notification Issued Date: N/A

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been

deleted

from this policy:

0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been

added

to this policy:

0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been

revised

in this policy:

0165U

Policy Attachment

Attachment to Policy #

MA00.010as

Attachment:

Policy #:

MA00.010as

Description:

Radiology Network Rules and Limited Circumstances cont'd.

Title:

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

RADIOLOGY NETWORK RULES AND LIMITED CIRCUMSTANCES

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST

CARDIOLOGIST, PEDIATRIC CARDIOLOGIST, INTERVENTIONAL CARDIOLOGIST, CLINICAL CARDIAC ELECTROPHYSIOLOGIST & ADVANCED HEART FAILURE AND TRANSPLANT SURGEON (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
78429	04-01-2021
78430	04-01-2021
78431	04-01-2021
78432	04-01-2021
78433	04-01-2021
78434	04-01-2021
78459	04-01-2021
78491	04-01-2021
78492	04-01-2021

CARDIOLOGIST, PEDIATRIC CARDIOLOGIST, INTERVENTIONAL CARDIOLOGIST, CLINICAL CARDIAC ELECTROPHYSIOLOGIST & ADVANCED HEART FAILURE AND TRANSPLANT SURGEON (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
78451	01-01-2010
78452	01-01-2010
78453	01-01-2010
78454	01-01-2010
78460	01-01-1988	12-31-2009
78461	01-01-1988	12-31-2009
78464	01-01-1988	12-31-2009
78465	01-01-1988	12-31-2009
78466	01-01-1988
78468	01-01-1988
78469	01-01-1988
78472	01-01-1988
78473	01-01-1992
78478	01-01-1992	12-31-2009
78480	01-01-1992	12-31-2009
78481	01-01-1988
78483	01-01-1992
78494	01-01-1999
78496	01-01-1999
93303	01-01-1997
93304	01-01-1997
93306	01-01-2009
93307	01-01-1982
93308	01-01-1982
93312	01-01-1989
93314	01-01-1993
93315	01-01-1997
93317	01-01-1997
93318	01-01-2001
93319	1-01-2022
93320	01-01-1982
93321	01-01-1990
93325	01-01-1990
93350	01-01-1990
93351	01-01-2009
93875	01-01-1992	12-31-2011

Nurse Midwife (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
S8055	09-25-2023
76801	09-25-2023
76802	09-25-2023
76805	09-25-2023
76810	09-25-2023
76811	09-25-2023
76812	09-25-2023
76813	09-25-2023
76814	09-25-2023
76815	09-25-2023
76816	09-25-2023
76817	09-25-2023
76825	09-25-2023
76826	09-25-2023
76827	09-25-2023
76828	09-25-2023
76830	09-25-2023
76831	09-25-2023
76856	09-25-2023
76857	09-25-2023
76999	09-25-2023

PEDIATRIC CARDIOLOGIST (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76820	04-01-2024
76821	04-01-2024
76825	07-01-2009
76826	07-01-2009
76827	07-01-2009
76828	07-01-2009

OTORHINOLARYNGOLOGIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
70300	01-01-1984
70310	01-01-1984
70320	01-01-1984
70350	01-01-1984
70355	01-01-1984
70371	01-01-1988

OBSTETRICIAN-GYNECOLOGIST, MATERNAL FETAL, OBSTETRICS, GYNECOLOGIST AND REPRODUCTIVE ENDOCRINOLOGIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0202	01-01-2002	12/31/2017
G0204	01-01-2002	12/31/2017
G0206	01-01-2002	12/31/2017
S8055	01-01-2002
76801	01-01-2003
76802	01-01-2003
76805	01-01-1982
76810	01-01-1992
76811	01-01-2003
76812	01-01-2003
76813	01-01-2007
76814	01-01-2007
76815	01-01-1982
76816	01-01-1986
76817	01-01-2003
76818	01-01-1986
76819	01-01-2001
76820	01-01-2005
76821	01-01-2005
76825	01-01-1986
76826	01-01-1993
76827	01-01-1993
76828	01-01-1993
76830	01-01-1990
76831	01-01-1998
76856	01-01-1982
76857	01-01-1986
76999	01-01-1984
77051	01-01-2007	12-31-2016
77052	01-01-2007	12-31-2016
77055	01-01-2007	12-31-2016
77056	01-01-2007	12-31-2016
77057	01-01-2007	12-31-2016
77063	01-01-2016
77065	01-01-2017
77066	01-01-2017
77067	01-01-2017
93325	01-01-1990

Female Pelvic Reconstructive Surgery (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76830	10-01-2015
76831	10-01-2015
76856	10-01-2015
76999	10-01-2015

Female Pelvic Reconstructive Surgery (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76857	10-01-2015

Female Pelvic Reconstructive Surgery (Outpatient Hospital Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76830-26	10-01-2015
76831-26	10-01-2015
76856-26	10-01-2015
76857-26	10-01-2015

OBSTETRICIAN-GYNECOLOGIST, MATERNAL FETAL, OBSTETRICS, GYNECOLOGIST AND REPRODUCTIVE ENDOCRINOLOGIST (Outpatient Hospital Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76801-26	01-12-2011
76802-26	01-12-2011
76805-26	01-12-2011
76810-26	01-12-2011
76811-26	01-12-2011
76812-26	01-12-2011
76813-26	07-01-2011
76814-26	07-01-2011
76815-26	01-12-2011
76816-26	01-12-2011
76817-26	01-12-2011
76818-26	01-12-2011
76819-26	01-12-2011
76820-26	01-12-2011
76821-26	01-12-2011
76825-26	01-12-2011
76826-26	01-12-2011
76827-26	01-12-2011
76828-26	01-12-2011
76830-26	01-12-2011
76831-26	07-01-2011
76856-26	01-12-2011
76857-26	01-12-2011
93325-26	07-01-2011

HEMATOLOGY/ONCOLOGIST, MEDICAL ONCOLOGIST AND PEDIATRIC HEMATOLOGY/ONCOLOGIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
79005	01-01-2005

OPHTHALMOLOGY AND PEDIATRIC OPHTHALMOLOGY (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76510	01-01-2005
76511	01-01-1982
76512	01-01-1982
76513	01-01-1988
76514	01-01-2004
76516	01-01-1982
76519	01-01-1986
76529	01-01-1982

OPTOMETRY (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76510	07-01-2024
76511	07-01-2024
76512	07-01-2024
76513	07-01-2024
76514	01-12-2011
76516	07-01-2024
76519	07-01-2024
76529	07-01-2024

ORAL SURGERY (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
70300	01-01-1984
70310	01-01-1984
70320	01-01-1984
70328	01-01-1984
70330	01-01-1984
70350	01-01-1984
70355	01-01-1984

ORTHOPEDIC SURGEON, HAND SURGEON, SPORTS MEDICINE, ORTHOPEDIC SPORTS MEDICINE & PEDIATRIC SPORTS MEDICINE SPECIALIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
72010	01-01-1986	12/31/2015
72020	01-01-1984
72040	01-01-1984
72050	01-01-1984
72052	01-01-1984
72069	01-01-1991	12/31/2015
72070	01-01-1984
72072	01-01-1984
72074	01-01-1984
72080	01-01-1984
72081	01-01-2016
72082	01-01-2016
72083	01-01-2016
72084	01-01-2016
72090	01-01-1984	12/31/2015
72100	01-01-1984
72110	01-01-1984
72114	01-01-1984
72120	01-01-1984
72170	01-01-1984
72190	01-01-1984
72200	01-01-1984
72202	01-01-1984
72220	01-01-1985
73000	01-01-1984
73010	01-01-1984
73020	01-01-1984
73030	01-01-1984
73050	01-01-1984
73060	01-01-1984
73070	01-01-1984
73080	01-01-1984
73090	01-01-1984
73092	01-01-1984
73100	01-01-1984
73110	01-01-1984
73120	01-01-1984
73130	01-01-1984
73140	01-01-1984
73500	01-01-1984	12/31/2015
73501	01-01-2016
73502	01-01-2016
73503	01-01-2016
73510	01-01-1984	12/31/2015
73520	01-01-1984	12/31/2015
73521	01-01-2016
73522	01-01-2016
73523	01-01-2016
73540	01-01-1984	12/31/2015
73550	01-01-1984	12/31/2015
73551	01-01-2016
73552	01-01-2016
73560	01-01-1984
73562	01-01-1984
73564	01-01-1983
73565	01-01-1991
73590	01-01-1984
73592	01-01-1984
73600	01-01-1984
73610	01-01-1984
73620	01-01-1984
73630	01-01-1984
73650	01-01-1984
73660	01-01-1984
77071	01-01-2007

PODIATRIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
73600	01-01-1984
73610	01-01-1984
73620	01-01-1984
73630	01-01-1984
73650	01-01-1984
73660	01-01-1984

RHEUMATOLOGIST AND PEDIATRIC RHEUMATOLOGIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0130	01-01-1999
77078	01-01-2007
77079	01-01-2007	12-31-2011
77080	01-01-2007
77081	01-01-2007
78351	01-01-1986

RADIATION ONCOLOGIST AND THERAPIST (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
0394T	01-01-2016
0395T	01-01-2016
G0562	01-01-2025
G6003	01-01-2015
G6004	01-01-2015
G6005	01-01-2015
G6006	01-01-2015
G6007	01-01-2015
G6008	01-01-2015
G6009	01-01-2015
G6010	01-01-2015
G6011	01-01-2015
G6012	01-01-2015
G6013	01-01-2015
G6014	01-01-2015
G6015	01-01-2015
G6016	01-01-2015
G6017	01-01-2015
Q3001	01-01-2001
76145	01-01-2021
77261	01-01-1984
77262	01-01-1984
77263	01-01-1984
77280	01-01-1984
77285	01-01-1984
77290	01-01-1984
77293	08-19-2019
77295	01-01-1994
77300	01-01-1984
77301	01-01-2002
77305	01-01-1984	12-31-2014
77306	01-01-2015
77307	01-01-2015
77310	01-01-1984	12-31-2014
77315	01-01-1984	12-31-2014
77316	01-01-2015
77317	01-01-2015
77318	01-01-2015
77321	01-01-1984
77326	01-01-1984	12-31-2014
77327	01-01-1984	12-31-2014
77328	01-01-1984	12-31-2014
77331	01-01-1984
77332	01-01-1984
77333	01-01-1984
77334	01-01-1984
77336	01-01-1984
77338	01-01-2010
77370	01-01-1984
77385	01-01-2015
77386	01-01-2015
77401	01-01-1991
77402	01-01-1991
77403	01-01-1991
77404	01-01-1991	12-31-2014
77406	01-01-1991	12-31-2014
77407	01-01-1991
77408	01-01-1991	12-31-2014
77409	01-01-1991	12-31-2014
77411	01-01-1991	12-31-2014
77412	01-01-1991
77413	01-01-1991	12-31-2014
77414	01-01-1991	12-31-2014
77416	01-01-1991	12-31-2014
77418	01-01-2002	12-31-2014
77422	01-01-2006
77423	01-01-2006
77427	01-01-2000
77431	01-01-1991
77432	01-01-1994
77470	01-01-1984
77499	01-01-1984
77600	01-01-1986
77605	01-01-1986
77610	01-01-1986
77615	01-01-1986
77620	01-01-1988
77750	01-01-1984
77761	01-01-1984
77762	01-01-1984
77763	01-01-1984
77767	01-01-2016
77768	01-01-2016
77770	01-01-2016
77771	01-01-2016
77772	01-01-2016
77776	01-01-1983	12/31/2015
77777	01-01-1984	12/31/2015
77778	01-01-1984
77781	01-01-1991	12-31-2008
77782	01-01-1991	12-31-2008
77783	01-01-1991	12-31-2008
77784	01-01-1991	12-31-2008
77785	01-01-2009	12/31/2015
77786	01-01-2009	12/31/2015
77787	01-01-2009
77789	01-01-1984
77790	01-01-1984
79005	01-01-2005

RADIATION ONCOLOGIST AND THERAPIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
77417	01-01-1991

CARDIOLOGIST, PEDIATRIC CARDIOLOGIST, INTERVENTIONAL CARDIOLOGIST, CLINICAL CARDIAC ELECTROPHYSIOLOGIST, ADVANCED HEART FAILURE AND TRANSPLANT SURGEON, SURGEON, PEDIATRIC SURGEON, NEUROLOGIST, PEDIATRIC NEUROLOGIST, VASCULAR SURGEON AND VASCULAR MEDICINE SPECIALIST, THORACIC SURGEON (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
93875	01-01-1992	12-31-2011
93880	01-01-1992
93882	01-01-1992
93886	01-01-1992
93888	01-01-1992
93890	01-01-2005	01-01-2025
93892	01-01-2005
93893	01-01-2005
93896	01-01-2025
93897	01-01-2025
93898	01-01-2025
93922	01-01-1994
93923	01-01-1994
93924	01-01-1994
93925	01-01-1992
93926	01-01-1992
93930	01-01-1992
93931	01-01-1992
93965	01-01-1992	12-31-2016
93970	01-01-1992
93971	01-01-1992
93975	01-01-1992
93976	01-01-1992
93978	01-01-1992
93979	01-01-1992
93980	01-01-1993
93981	01-01-1993
93985	01-01-2020
93986	01-01-2020
93990	01-01-1995

VASCULAR AND INTERVENTIONAL RADIOLOGIST (Office Place of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
93970	07-01-2021
93971	07-01-2021

VASCULAR AND INTERVENTIONAL RADIOLOGIST (Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
93880	01-01-2016
93882	01-01-2016
93886	01-01-2016
93888	01-01-2016
93890	01-01-2016	01-01-2025
93892	01-01-2016
93893	01-01-2016
93896	01-01-2025
93897	01-01-2025
93898	01-01-2025
93922	01-01-2016
93923	01-01-2016
93924	01-01-2016
93925	01-01-2016
93926	01-01-2016
93930	01-01-2016
93931	01-01-2016
93970	01-01-2016
93971	01-01-2016
93975	01-01-2016
93976	01-01-2016
93978	01-01-2016
93979	01-01-2016
93980	01-01-2016
93981	01-01-2016
93985	01-01-2020
93986	01-01-2020
93990	01-01-2016

SURGEON (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76098	07-01-2009

UROLOGIST (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
76857	01-01-1986
76872	12-16-2024
76873	01-01-2000
93980	01-01-1993
93981	01-01-1993

NUCLEAR MEDICINE SPECIALIST (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0219	01-01-2002
G0252	10-01-2002
S8085	01-01-2001
77080	12-16-2024
77081	12-16-2024
77085	12-16-2024
77086	12-16-2024
78000	01-01-1984	01-01-2013
78001	01-01-1984	01-01-2013
78003	01-01-1984	01-01-2013
78006	01-01-1984	01-01-2013
78007	01-01-1984	01-01-2013
78010	01-01-1984	01-01-2013
78011	01-01-1984	01-01-2013
78015	01-01-1984
78016	01-01-1984
78018	01-01-1984
78020	01-01-1999
78070	01-01-1989
78075	01-01-1984
78099	01-01-1984
78103	01-01-1984
78104	01-01-1984
78110	01-01-1984
78111	01-01-1984
78120	01-01-1984
78121	01-01-1984
78122	01-01-1987
78130	01-01-1984
78135	01-01-1984	01-01-2021
78140	01-01-1984
78185	01-01-1984
78190	01-01-1991
78191	01-01-1984
78195	01-01-1984
78199	01-01-1984
78202	01-01-1984
78205	01-01-1988	01-01-2020
78206	01-01-1999	01-01-2020
78215	01-01-1984
78216	01-01-1984
78220	01-01-1984	12-31-2011
78223	01-01-1984	12-31-2011
78230	01-01-1984
78231	01-01-1984
78232	01-01-1984
78258	01-01-1987
78261	01-01-1984
78262	01-01-1984
78264	01-01-1984
78267	01-01-2000
78268	01-01-2000
78270	01-01-1985
78271	01-01-1985
78272	01-01-1984
78282	01-01-1985
78290	01-01-1984
78291	01-01-1985
78299	01-01-1984
78300	01-01-1984
78305	01-01-1984
78306	01-01-1984
78315	01-01-1987
78320	01-01-1988	01-01-2020
78350	01-01-1986
78351	01-01-1986
78399	01-01-1984
78414	01-01-1984
78428	01-01-1984
78429	01-01-2020
78430	01-01-2020
78431	01-01-2020
78432	01-01-2020
78433	01-01-2020
78434	01-01-2020
78445	01-01-1984
78456	01-01-2000
78457	01-01-1984
78458	01-01-1984
78460	01-01-1988	12-31-2009
78461	01-01-1988	12-31-2009
78464	01-01-1988	12-31-2009
78465	01-01-1988	12-31-2009
78466	01-01-1988
78468	01-01-1988
78469	01-01-1988
78472	01-01-1988
78473	01-01-1992
78478	01-01-1992	12-31-2009
78480	01-01-1992	12-31-2009
78481	01-01-1988
78483	01-01-1992
78491	01-01-1998
78492	01-01-1998
78494	01-01-1999
78496	01-01-1999
78499	01-01-1984
78580	01-01-1984
78585	01-01-1984	12-31-2011
78586	01-01-1984	12-31-2011
78587	01-01-1984	12-31-2011
78588	01-01-1999	12-31-2011
78591	01-01-1984	12-31-2011
78593	01-01-1984	12-31-2011
78594	01-01-1984	12-31-2011
78596	01-01-1991	12-31-2011
78599	01-01-1984
78600	01-01-1984
78601	01-01-1984
78605	01-01-1984
78606	01-01-1984
78607	01-01-1988	01-01-2020
78608	01-01-1994
78609	01-01-1994
78610	01-01-1984
78615	01-01-1984	12-31-2007
78630	01-01-1984
78645	01-01-1984
78647	01-01-1995	01-01-2020
78650	01-01-1984
78660	01-01-1984
78699	01-01-1984
78700	01-01-1984
78701	01-01-1984
78707	01-01-1984
78708	01-01-1998
78709	01-01-1998
78710	01-01-1988	01-01-2020
78725	01-01-1984
78730	01-01-1984
78740	01-01-1984
78761	01-01-1984
78799	01-01-1984
78800	01-01-1984
78801	01-01-1984
78802	01-01-1984
78804	01-01-2004
78805	01-01-1984	01-01-2020
78806	01-01-1984	01-01-2020
78807	01-01-1994	01-01-2020
78808	01-01-2009
78811	01-01-2005
78812	01-01-2005
78813	01-01-2005
78814	09-01-2015
78815	12-23-2011
78816	09-01-2015
78999	01-01-1984
79005	01-01-2005
79101	01-01-2005
79200	01-01-1984
79300	01-01-1984
79403	01-01-2004
79445	01-01-2005
79999	01-01-1982

INTERVENTIONAL RADIOLOGIST (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
75635	01-01-2001
78195	01-01-1984

INFECTIOUS DISEASE AND GASTROENTEROLOGY (Office and Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
91200	04-15-2016

Version Effective Date:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A

Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Policy Attachment

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST​​​​​​​

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST