MA PPO
Advanced Search

MA PPO Host - Medical Policy Bulletin

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010as

​

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy applies to providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Preferred Provider Organization (PPO) Company products.

The PPO Network Rules and limited circumstances are as follows:

DURABLE MEDICAL EQUIPMENT RULES AND LIMITED CIRCUMSTANCES
  • Durable medical equipment (DME) (which includes prosthetics and orthotics) under the PPO benefit program (DME Network Rules and Limited Circumstances, Attachments A1 and A2) is considered eligible for payment in an office, in an outpatient setting, and in a home setting, when supplied by an ancillary provider with the DME specialty, such as DME and pharmacy/DME.
  • The limited circumstances of DME services that a participating specialist (this includes certified registered nurse practitioners [CRNPs] and Physician Assistants [PAs] practicing within these specialty groups), other than a DME provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment A3. Refer to Attachment A3 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide DME/prosthetic/orthotic equipment, unless otherwise identified by specialty and code in attachment A3.
LABORATORY RULES AND LIMITED CIRCUMSTANCES
  • Laboratory services under the PPO benefit program are determined by the Bureau of Laboratories, and defined by the Pennsylvania Department of Health. For the PPO line of business, all laboratory services listed in Attachment B1 of this policy are considered eligible for payment in an office or outpatient setting, when performed by any type of participating PPO provider. Laboratory services listed in Attachment B2.1 or B2.2 of this policy are only eligible for payment when performed by an independent or a physiological laboratory.
  • The limited circumstances of laboratory services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment B3 of this policy.
  • All other provider specialties are considered ineligible to provide laboratory services, unless otherwise identified by specialty and code in attachment B3.
RADIOLOGY RULES AND LIMITED CIRCUMSTANCES
  • Radiology services under the PPO benefit program (Radiology Network Rules and Limited Circumstances, Attachment C1) are considered eligible for payment in an outpatient and office setting when performed by a radiologist or pediatric radiologist at a contracted radiology site.
  • The limited circumstances of radiology services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than a radiology provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment C2. Refer to attachment C2 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide radiology services, unless otherwise identified by specialty and code in attachment C2.
PHYSICAL MEDICINE AND REHABILITATIVE RULES AND LIMITED CIRCUMSTANCES
  • Physical medicine and rehabilitative services under the PPO benefit program (Physical Medicine and Rehabilitation Network Rules and Limited Circumstances, Attachment D) are considered eligible for payment in an office and outpatient setting, when performed by a physical therapist at a contracted physical therapy site.
  • The limited circumstances of physical medicine and rehabilitative services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than a physical therapist provider, and for which the provider may be eligible for reimbursement, are also listed in Attachment D. Refer to Attachment D for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide physical medicine and rehabilitative services, unless otherwise identified by specialty and code in Attachment D.
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Inclusion of a code in this policy does not imply coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Description

​This Network Rules policy documents the Company’s reimbursement position for participating Preferred Provider Organization (PPO) professional and ancillary providers who supply durable medical equipment (DME) and perform laboratory, radiology, and physical medicine and rehabilitative services. This policy addresses these services provided in the office or outpatient settings, in the home setting for DME, and at an independent laboratory for laboratory services. The Network Rules policy identifies the specific provider specialties that are eligible for payment when billing Current Procedural Terminology (CPT) or Healthcare Common Procedural Coding System (HCPCS) codes within the four service or equipment types, as defined below:
  • DME (which includes prosthetics and orthotics) refers to equipment and/or a device that meets the following identified criteria:
    • DME criteria:
      • It is durable and can withstand repeated use.
      • It is medical equipment, meaning it is primarily and customarily used to serve a medical purpose.
      • It generally is not useful to an individual in the absence of an illness or injury.
      • It is appropriate for use in the home.
    • Prosthetics criteria:
      • Prosthetics are devices that replace all or part of either of the following:
        • An absent body organ, including contiguous tissue
        • The function of a permanent inoperative or malfunctioning body organ
    • Orthotics criteria:
      • Orthotics are fabricated or fitted braces or supports (in some cases custom) that are designed to provide alignment/correction in or prevention of neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
  • Laboratory services are tests that are performed on biological specimens in order to obtain information about an individual’s health. These tests, which involve measurements, are conducted under controlled conditions.
  • Radiology services encompass the scientific discipline of medical imaging, which utilizes ionization radiation, radionuclides, magnetic resonance, and ultrasound.
  • Physical medicine and rehabilitative care services consist of the combined use of medical, physical, social, technological, educational, and vocational services that enable individuals with disabilities or impairments resulting from disease, injury, prior therapeutic intervention, or congenital anomaly to achieve the highest possible level of functional ability and/or independence in activities of daily living.
Network Rules for provision of specialty services include limited circumstances when participating PPO professional and ancillary providers, other than the designated specialty providers, may be eligible for payment for the provision of certain specialty services. These limited circumstances are identified by specific selected procedures that are eligible when billed by providers with specific specialties in an office or outpatient setting.

References

Agency for Healthcare Research and Quality (AHRQ). Vision rehabilitation for elderly individuals with low vision or blindness. Available at:
https://www.cms.gov/Medicare/Coverage/InfoExchange/downloads/rtcvisionrehab.pdf. Accessed March 8, 2023. 

American Optometric Association. Low vision. Available at: https://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision. Accessed March 8, 2023. 

Company Provider Contracts.​
ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. Low Vision Rehabilitation. Available at:
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf. Accessed March 8, 2023. 

Coding

CPT Procedure Code Number(s)
See Attachments.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment D.
HCPCS Level II Code Number(s)
See Attachments.
Revenue Code Number(s)
N/A

​

Coding and Billing Requirements

BILLING REQUIREMENTS

Services performed in the outpatient setting are subject to facility global payment rules. The presence of a code on the exception list will not result in separate payment to the professional provider when the reimbursement to the facility includes payment for both the professional and the technical component of the service.

Cross Reference

Policy History

Revisions From MA00.010as:

01/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2025. 

The following CPT codes have been deleted from this policy: 


81433, 81436, 81438, 86327, 86490, 0346U, 0352U, 0380U, 0428U, 0448U, 0500T, 

93890, 88388.


The following CPT and HCPCS codes have been added to this policy: ​

76014, 76015, 76016, 76017, 76018, 76019, 93896, 93897, 93898, G0562, 

81515, 87626, E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1827, E1828, E1829.​

The following CPT and HCPCS code narratives have been revised in this policy:

81432, 81435, 81437, 0095U, 0365U, 87624, 88387, 93893, E1800, E1805, E1810, E1815, E1825, E1830.


Revisions From MA00.010ar:

12/16/2024

This version of the policy will become effective 12/16/2024. Policy number MA00.010ar​is being issued to introduce a radiology network rule exception allowing reimbursement for Dual-Energy X-ray Absorptiometry (DXA), when performed in the office setting by Nuclear Medicine specialty. In addition, Transrectal Ultrasound is being introduced as a radiology network rule exception allowing reimbursement when performed in the office setting by Urology specialty, as identified in this policy.  

Nuclear Medicine provider specialty has been added to the following codes in Attachment C2:

77080, 77081, 77085, and 77086 

In addition, Urology provider specialty has been added to the following code in Attachment C2:

76872


Revisions From MA00.010aq:

10/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2024. 

The following CPT & HCPCS codes have been added to this policy: 
0476U, 0477U, 0478U, 0483U, 0484U, 0485U, 0486U, 0487U, 0488U, 0489U
0490U, 0491U, 0492U, 0495U, 0496U, 0497U, 0498U, 0499U , 0500U ,0501U
0502U, 0504U, 0505U, 0506U ,0507U, 0510U, 0511U, 0512U ,0513U , 0514U
0515U, Attachment B2.1


E2513, Attachment A1


L1006, L1653, L1821, L8720, L8721, Attachment A2

The following CPT & HCPCS code narratives have been revised in this policy:

0248U, 0403U, E0739, L1652, L1820​


Revisions From MA00.010ap:

07/01/2024

This version of the policy will become effective 07/01/2024.  


This policy is being issued to introduce a radiology network rule exception that allows reimbursement for ophthalmic ultrasounds when performed in the​ office setting by an optometry specialist, as indicated in the policy.  

​

The optometry provider type has been added to the following codes in Attachment C2:


76510, 76511, 76512, 76513, 76516, 76519, 76529


Revisions From MA00.010ao:

04/01/2024

This version of the policy will be issued on  04/19/2024 with a retroactive effective date of 04/01/2024.​  Policy number MA00.010ao ris being issued to introduce a radiology network rule exception allowing reimbursement for doppler ultrasounds when performed in the office setting by Pediatric Cardiology ​providers, as identified in this policy.


Pediatric Cardiology provider type has been added to the following codes in Attachment C2:

​76820 and 76821  


In addition, this policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2024. 

The following HCPCS codes have been added to this policy:

0439U, 0440U, 0441U, 0442U, 0443U, 0444U, 0445U, 0446U, 0447U, 0448U and

0449U, A4564, A4593, A4594, E0152, E0468, E0736, E0739, E2104, E2298, K1037, L1320, L5783, L5841, S4988 and S9002


​The following HCPCS codes have been deleted from this policy: 
 

0354U, 0416U and E2300


The following HCPCS code narratives have been revised this policy: 
A4561 and E2001


Revisions From MA00.010an:

01/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024. 

The following CPT codes have been deleted from this policy: 
 
K1001, K1002, K1003, K1005, K1006, K1009, K1013, K1020, K1023, K1024, K1025, K1026,  74710.

The following CPT & HCPCS codes have been added to this policy: 

0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0427U, 0428U, 0429U, 0430U, 0431U, 0432U, 0433U, 0434U, 0435U, 0436U, 0437U, 0438U 81457, 81458, 81459, 81462, 81463, 81464, 81517, 82166, 86041, 86042, 86043, 86366, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T,  0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 87523, 75580, 76987, 76988, 0815T, 0857T, 0865T, 0866T, A4287, A4457, A4540, A7023, E0530, E0680, E0678, E0679, E0681, E0682, E0732, E0735, E1301, E2001, E3000.


The following CPT & HCPCS code narratives have been revised in this policy: 


A6531, A6532, A6545.


Revisions From MA00.010am:

​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​​
10/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 10/1/2023. 

The following CPT code has been deleted from this policy:

0386U

The following CPT and HCPCS codes have been added to this policy:

0019M, 0403U, 0404U, 0405U, 0406U, 0407U, 0409U, 0410U, 0411U, 0413U, 
0414U, 0416U, 0417U, 0418U, B4148, K1036

The following CPT & HCPCS code narratives have been revised in this policy:

0269U, 0271U, 0272U, 0274U, 0278U, A4344 and K1004


In addition, the following HCPCS codes have been added to this policy as a result of the 4/1/2023 Quarterly Code Updates:


A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, E1905, K1035, L8678​


Revisions From MA00.010al:

09/25/2023​

This version of the policy will become effective 09/25/2023.  This policy number MA00.010al​​ has been updated to introduce a radiology network rule exception to allow reimbursement consideration by the Company when performed in the office setting by Nurse Midwife specialty, as identified in this policy.


Nurse Midwife provider type has been added to the following codes in Attachment C2:  

S8055, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817,  

76825,  76826, 76827, 76828, 76830, 76831, 76856, 76857, 76999​


In addition, as a result of Podiatry provider inquiry, the following CPT code has been removed from the Physical Medicine and Rehabilitation Network Rules and Limited Circumstances, Attachment D​ of this policy.

97610​​


Revisions From MA00.010ak:

04/01/2023

 This version of the policy will become effective 04/01/2023. This policy has been updated to introduce a lab network rule exception for Respiratory Syncytial Virus (RSV) and Streptococcus services​​ to all provider specialty types when performed in the office setting.


The following CPT codes have been added to Attachment B1 of this policy: 

87634, 87651 and 87807​ 


In addition, this policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2023


The following CPT codes have been deleted from this policy: 
G2023, G2024, U0003, U0004 and U0005


The following CPT codes have been added to this policy:  

0364U, 0365U, 0366U, 0367U, 0368U, 0370U, 0371U, 0372U, 0373U, 0374U, 

0375U, 0376U, 0379U, 0380U, 0381U, 0384U, 0385U, 0386U


The following CPT code narratives have been revised in this policy: 
0022U 0095U and A4628​


Revisions From MA00.010aj:

12/05/2022

This version of the policy will become effective 12/05/2022


Policy number MA00.010aj is being issued to introduce a radiology network rule exception to allow reimbursement consideration by the Company when performed in the office setting by Orthopedic Sports Medicine specialty providers, as identified in this policy.

Orthopedic Sports Medicine provider type has been added to the following codes in Attachment C2:  72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080,  72081, 72082, 72083, 72084, 72100, 72110, 72114, 72120, 72170, 72190 ,72200, 72202, 72220, 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 73501, 73502, 73503, 73521, 73522, 73523, 73551, 73552, 73560, 73562, 73564, 73565, 73590, 73592, 77071 73600, 73610, 73620, 73630, 73650, and 73660


Revisions From MA00.010ai:

10/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 10/1/2022.

 

The following CPT & HCPCS codes have been deleted from this policy: 

0012U

 

The following CPT & HCPCS codes have been added to this policy:

A4596, E0183, 0332U, 0333U, 0334U, 0335U, 0336U, 0337U, 0338U, 0339U, 0340U, 0341U, 0342U, 0343U, 0344U, 0345U, 0346U, 0347U, 0348U, 0349U, 0350U, 0351U, 0352U, 0353U, 0354U

 

The following CPT/HCPCS code narratives have been revised in this policy:

0276U and E0483​​​


Revisions From MA00.010ah:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/1/2022. 

The following CPT & HCPCS codes have been deleted from this policy: 
0097U and 0151U

The following CPT & HCPCS codes have been added to this policy: 

0306U, 0307U, 0308U, 0309U, 0310U, 0311U, 0312U, 0313U, 0314U, 0315U, 0316U, 0317U, 0318U, 0319U, 0320U, 0321U 0322U, A4238 and E2102​


Revisions From MA00.010ag:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/1/2022. 

The following CPT & HCPCS codes have been deleted from this policy: 0423T, 76101,
76102, 80500, 80502, and A4397

The following CPT & HCPCS codes have been added to this policy: 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0295U, 0296U, 0297U, 0298U, 0299U, 0300U, 0301U, 0302U, 0303U, 0304U, 0305U, 0689T, 0690T, 0691T, 0694T, 0697T, 0698T, 0701T, 77089, 77090, 77091, 77092, 80220, 80503, 80504, 80505, 80506, 81349, 81523, 81560, 82653, 83521, 83529, 86015, 86036, 86037, 86051, 86052, 86053, 86231, 86258, 86362, 86363, 86364, 86381, 86596, 87154, 93319, and E1629 

The following HCPCS code narrative has been revised in this policy: 0648T, 0649T, 75573, 81228, 81229, 82656, and 87426​​


Revisions From MA00.010af:

10/01/2021

This policy has been identified for the 10/1/2021 Quarterly Code Update. This version of the policy will become effective 10/01/2021. ​

The following CPT codes have been deleted from this policy: 0139U, 0168U

The following CPT & HCPCS codes have been added to this policy: A4453, K1021, K1023, K1024, K1025, K1026, K1027, 0018M, 0255U, 0256U, 0257U, 0258U, 0259U, 0260U, 0261U, 0262U, 0263U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0275U, 0276U, 0277U, 0278U, 0279U, 0280U, 0281U, 0282U, 0283U, 0284U

The following HCPCS code narrative has been revised in this policy: K1013​


Revisions From MA00.010ae:

07/01/2021

This version of the policy will become effective 07/01/2021.

Policy number MA00.010ae is being issued to introduce a radiology network rule exception to allow reimbursement consideration by the Company for doppler studies when performed in the office setting by Vascular & Interventional Radiology specialty providers, as identified in this policy.

Vascular & Interventional Radiology provider type has been added to the following codes in Attachment C2: 93970, 93971

In addition, this policy has been impacted by the 07/01/2021 Quarterly Code Update​.
The following codes have been added to Attachment B2: 0248U, 0249U, 0250U, 0251U, 0252U, 0253U, 0254U, G0327

The following codes have been added to Attachment C1: 0648T, 0649T

 
Revisions From MA00.010ad:
04/02/2021This version of the policy will become effective 04/02/2021. 

In addition to codes previously included in Policy Update version bb as part of the 4/1/2021 Quarterly Code Update​, later released HCPCS codes have also been identified for this Code Update. 

The following HCPCS codes have been added to Attachment A2: K1013, K1020

Revisions From MA00.010ac:
04/01/2021This version of the policy will become effective 04/01/2021. 

Policy number MA00.010ac is being issued to introduce a radiology network rule exception to allow reimbursement for cardiac PET scan procedures done in the office setting when performed by cardiology specialty providers identified in this policy. 

The following CPT codes have been added to Attachment C2: 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492

In addition, this policy has been identified for the 04/01/2021 Quarterly Code Update.

The following CPT codes have been added to Attachment B2: 0242U, 0243U, 0244U, 0245U, 0246U, 0247U

The following CPT codes have been deleted from Attachment B2: 0098U, 0099U, 0100U​

​Revisions From MA00.010ab:
01/01/2021This policy has been identified for the Annual Code Update. This version of the policy will become effective 01/01/2021. ​

The following CPT codes have been deleted from this policy: 0085T, 0111T, 76970, 78135, 81545

The following CPT & HCPCS codes have been added to this policy: 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, 81513, 81514, 81529, 81546, 81554, 82077, 82681, U0005, 0017M, 0225U, 0226U, 0227U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76145

The following CPT & HCPCS code narratives have been revised in this policy: 70250, 71250, 71260, 71270, 74400, 74410, 74415, 74420, 74425, 76510, 76511, 76512, 76513, 78130, 80414, 80415, 82075, 0152U​

Revisions From MA00.010aa:
10/01/2020This policy has been identified for the October Quarterly Code Update. This version of the policy will become effective 10/01/2020. Due to the COVID-19 Public Health Emergency, certain procedure codes have been released off-cycle and have varying effective dates. 

The following CPT & HCPCS codes have been added to this policy: 0015M, 0016M, 0203U, 0204U, 0205U, 0206U, 0207U, 0208U, 0209U, 0210U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0219U, 0220U, 0221U, 0222U, 0240U, 0241U, 86413, 87636, 87637, 87811, 87428, K1006, K1009, K1010, K1011, K1012​

This policy has been identified for the Quarterly Code Update. The code changes identified below became effective in this policy, 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

Revisions From MA00.010z:
05/18/2020This version of the policy will become effective 05/18/2020.

This policy is being updated to remove dermatology office place of service exceptions for certain laboratory services.
  • The following CPT codes have been deleted from Att B3: 88302, 88304, 88305, 88312, 88313, 88321, 88341, 88342

Revisions From MA00.010y:
04/01/2020This policy has been identified for the 04/01/2020 Quarterly Code Update. This version of the policy will become effective 04/01/2020.

The following CPT/HCPCS codes have been added to this policy: 0014M, 0163U, 0164U, 0165U, 0166U, 0167U, 0168U, 0169U, 0170U, 0171U, G2023, G2024, U0001, U0002, U0003, U0004, 86328, 86769, 87635

The following CPT codes have been revised in this policy: 0154U, 0155U

Revisions From MA00.010x:
01/01/2020This policy has been identified for the 1/1/2020 Annual Code Update. This version of the policy will become effective 01/01/2020.

· The following CPT/HCPCS codes have been deleted from this policy: 0081U, 0085U, 0482T, 74241, 74245, 74247, 74249, 74260, 78205, 78206, 78320, 78607, 78647, 78710, 78805, 78806, 78807, G0365, 97127, G0515
    · The following CPT/HCPCS codes have been added to this policy: 0564T, 80145, 80187, 80230, 80235, 80280, 80285, 81277, 81307, 81308, 81309, 81522, 81542, 81552, 87563, 0139U, 0140U, 0141U, 0142U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 0151U, 0152U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 80305, 80306, 78429, 78430, 78431, 78432, 78433, 78434, 74221, 74248, 93985, 93986, 97129, 97130, L8033, A4226, E0787, E2398, K1001, K1002, K1003, K1004, K1005
      · The following CPT/HCPCS code narratives have been revised in this policy: 81350, 74022, 74210, 74220, 74230, 74240, 74246, 74250, 74251, 74270, 74280, 78459, 78491, 78492, 78800, 78801, 78802, 78803, 78804, L8032, B4185
        · The following ICD 10 codes have been added to this policy: H53.411, H53.412, H53.413, H53.419, H53.429, H54.10, H54.40, H54.50, H54.60

        Revisions From MA00.010w:
        10/01/2019This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 10/01/2019.
          • The following CPT code has been deleted from this policy: 0104U
          • The following CPT codes have been added to this policy: 0105U, 0106U, 0107U, 0108U, 0109U, 0110U, 0111U, 0112U, 0113U, 0114U, 0115U, 0116U, 0117U, 0118U, 0119U, 0120U, 0121U, 0122U, 0123U, 0124U, 0125U, 0126U, 0127U, 0128U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U

        Revisions From MA00.010v:
        08/19/2019This version of the policy will become effective 08/19/2019.

        This policy was expanded to allow certain place of service and provider exceptions for influenza testing services.
        • The following CPT codes have been deleted from Att B2 and added to Att B1: 87501, 87502, 87503.

        In addition, this policy was expanded to allow the same exceptions for an add on code that may only be reported in conjunction with two primary radiation therapy codes that have specialist exceptions in place.
        • The following CPT code has been added to Att C2: 77293

        Revisions From MA00.010u:
        07/01/2019This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2019.

        The following CPT codes have been added to this policy:
        0084U, 0085U, 0086U, 0087U, 0088U, 0089U, 0090U, 0091U, 0092U, 0093U, 0094U, 0095U, 0096U, 0097U, 0098U, 0099U, 0100U, 0101U, 0102U, 0103U, 0104U. 0558T

        Revisions From MA00.010t:
        01/01/2019This version of the policy will become effective 01/01/2019.

        The following CPT & HCPCS codes have been deleted from this policy: 0346T, 77058, 77059, 78270, 78271, 78272, 81211, 81213, 81214, K0903.

        The following CPT & HCPCS codes have been added to this policy: E0447, E0467, A6460, A6461, L8698, 0541T, 0542T, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049, 81163, 81164, 81165, 81166, 81167, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81204, 81233, 81234, 81236, 81237, 81239, 81271, 81274, 81284, 81285, 81286, 81289, 81305, 81306, 81312, 81320, 81329, 81333, 81336, 81337, 81343, 81344, 81345, 81443, 81518, 81596, 82642, 83722, 0080U, 0081U, 0082U, 0083U.

        The following CPT & HCPCS codes have been revised in this policy: 77387, 81162, 81212, 81215, 81216, 81217, 81244, 81287, 81327, E0218, E0483.

        Revisions From MA00.010s:
        04/01/2018Revised policy number MA00.010s was issued effective 01/01/2018.

        The below limited circumstances have been removed from Attachment B3, effective 04/01/2018, and are no longer eligible for reimbursement when performed by participating physician specialty office-based pathologists or free-standing office pathology practices:
          • Service codes 88187, 88188, 88189, 88291, 88302 modifier 26, 88304 modifier 26, 88305, 88305 modifier 26, 88312 modifier 26, 88313 modifier 26, 88341 modifier 26 and 88342 modifier 26 when performed by a pathologist, anatomic pathologist, or anatomic and clinical pathologist in place of service office.
          • 88313, 88341, 88342, 88313 modifier 26, 88341 modifier 26, 88342 modifier 26, 88304 modifier 26, 88305 modifier 26, and 88312 modifier 26 when performed by a an oral and maxillofacial pathologist in place of service office.

          New code added: New code K0903 For diabetics only, multiple density insert, made by
          direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

        Revisions From MA00.010r:
        01/01/2018This policy becomes effective 01/01/2018.

        The following HCPCS codes have been added to Attachment A1 of this policy:

        E0953, E0954, L3761, L8625, L8694, L7700

        The following HCPCS code narratives have been revised to Attachment A2 of this policy:

        L3760, L8618, L8624, L8691

        The following CPT codes have been added to Attachment B2 of this policy:

        0011M, 0024U, 0025U, 0026U, 0027U, 0028U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0500T, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81175, 81176, 81230, 81231, 81232, 81238, 81247, 81248, 81249, 81258, 81259, 81269, 81283, 81328, 81334, 81335, 81346, 81361, 81362, 81363, 81364, 81448, 81520, 81521, 81541, 81551, 86794, 87634, 87662, 86008,

        The following CPT codes have been deleted from Attachment B2 of this policy:

        83499, 84061, 86185, 86243, 86378, 86729, 86822, 87277, 87470, 87477, 87515, 88154

        The following CPT code narratives have been revised to Attachment B2 of this policy:

        80305, 80306, 80307, 81257, 81432, 81439, 82042, 82043, 82044

        The following CPT codes have been added to Attachment C1 of this policy:

        0482T, 0501T, 0502T, 0503T, 0504T, 71045, 71046, 71047, 71048, 74018, 74019, 74021

        The following CPT codes have been deleted from Attachment C1 of this policy:

        71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 74000, 74010, 74020, 77422, 78190, G0202, G0204, G0206

        The following CPT code narratives have been revised to Attachment C1 of this policy:

        76000, 76881, 76882,

        The following CPT codes have been deleted from Attachment C2:

        G0202, G0204, G0206

        The following CPT codes have been added to Attachment D of this policy:

        97127, G0515, 97763

        The following CPT codes have been deleted from Attachment D of this policy:

        97532, 97762

        The following CPT code narratives have been revised to Attachment D of this policy:

        97760, 97761

        Revisions From MA00.010q:
        12/01/2017Physician Assistants (PAs) practicing within the scope of their license may be eligible to perform specific Durable medical equipment (DME), laboratory, radiology, Physical medicine and rehabilitative services in the speciality groups as outlined in Attachments A3, B3, C2, and D, effective 12/01/2017.

        Revisions From MA00.010p:
        10/01/2017This policy has been identified for the CPT/HCPCS code update.

        The following LAB CPT codes have been added to Attachment B2 of this policy, effective 10/01/2017: 0022U, 0023U

        The following 10/01/2017 LAB CPT codes have not been added to this policy due to Experimental/Investigational position: 0018U, 0019U, 0020U, 0021U

        The following ICD-10 codes have been added to Attachment D of this policy, effective 10/01/2017:

        H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.511A, H54.512A, H54.52A1, H54.52A2

        The following ICD-10 codes are termed and removed from attachment D of this policy, effective 09/30/2017:

        H54.0, H54.11, H54.12, H54.2, H54.41, H54.42, H54.51, H54.52,

        Revisions From MA00.010o:
        08/21/2017This policy has been identified for the CPT/HCPCS code update.

        The following DME HCPCS codes have been added to this policy, effective 07/01/2017:

        K0553, K0554

        The following LAB CPT codes have been added to this policy, effective 08/01/2017:

        0012U, 0016U, 0017U

        Specialty code 172 (Anatomic Pathology) has been added to Attachment B3 of this policy as an exception to pathology services.

        Revisions From MA00.010n:
        08/01/2017Certified Registered Nurse Practitioners (CRNPs) practicing within the scope of their license may be eligible to perform specific Durable medical equipment (DME), laboratory, radiology, Physical medicine and rehabilitative services in the speciality groups as outlined in Attachments A3, B3, C2, and D.

        The following language was added to the Policy section of this policy:

        REQUIRED DOCUMENTATION

        The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

        The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

        Revisions From MA00.010m:
        06/01/2017The following CPT codes have been added to attachment B3 (Lab exceptions) of this policy to be performed by a Reproductive Endocrinologist in an office or hospital outpatient place of service, effective 01/01/2017:

        82671,82672, 84704, 84830, 89335, 89337, 89352, 89353, 89354, 89356

        The following CPT codes have been added to attachment B1 ( eligible to all professional specialties in place of service office, independent lab, and outpatient hospital) of this policy, effective 06/01/2017:

        87808

        The following CPT codes have been added to attachment B2 (only eligible to Independent or Physiological labs in place of service independent lab) of this policy, effective 06/01/2017:

        80500, 80502, 81400, 83698, 87168, 87169, 89251, 89268, 89272, 89281, 89290, 89291

        Revisions From MA00.010l:
        01/01/2017This policy has been identified for the CPT code update, effective 01/01/2017.

        The following CPT codes have been termed from this policy:

        0286T, 0287T, 77051, 77052, 77055, 77056, 77057, 80300, 80301, 80302, 80303, 80304, 81280, 81281, 81282, 93965, 97001, 97002, 97003, 97004, 97005, 97006, A9545, B9000, E0628, K0901, K0902

        The following CPT / HCPCS codes have been added to this policy under Attachment A1:

        A4224, A4225, A4467, A4553, A9285, A9286, L1851, L1852

        The following CPT / HCPCS codes have been added to this policy under Attachment B2:

        0001U, 0002U, 0003U

        The following CPT / HCPCS codes have been added to this policy under Attachment C1:

        76706

        The following CPT / HCPCS codes have been added to this policy under Attachment C1 and also to Attachment C2 as an exception to be eligible for reimbursement when performed by an OB/GYN, Maternal Fetal Medicine), Obstetric, Gynecologist, and Reproductive Endocrinologist in place of service office:

        77065, 77066, 77067

        The following CPT / HCPCS codes have been added to Attachment C2 as an exception to be eligible for reimbursement when performed by a Radiation therapy physician specialist in place of service office and outpatient hospital, effective 01/01/2016:
        0394T, 0395T, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017, Q3001, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77306, 77307, 77316, 77317, 77318, 77321 , 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77385, 77386, 77401, 77402, 77403, 77407, 77412, 77417, 77422, 77423, 77427, 77431, 77432, 77470, 77499, 77600, 77605, 77610, 77615, 77620, 77750, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 77787, 77789, 77790, 79005

        The following CPT codes have been added to Attachment A2 as an exception to be eligible for reimbursement when performed by a Vascular and Interventional radiologist in place of service office outpatient hospital, effective 01/01/2016:

        93880, 93882, 93886, 93888, 93890, 93892, 93893, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981, 93990

        The following CPT / HCPCS codes have been added to this policy under Attachment D (Physical Medicine and Rehabilitation):

        97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172

        The following CPT narratives have been revised in this policy:

        77407, 77412, 83015, 83018, 83704, 87147, 87197, 87253, A4221, B9002, E0627, E0629, E0740, E0967, E0995, E2206, E2220, E2221, E2222, E2224, J7340, K0019, K0037, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0069, K0071, K0072, K0077, K0098, K0552, L1906

        Revisions From MA00.010k:
        01/01/2017
          The following language has been revised in the Policy section of this policy:

          FROM:

          LABORATORY RULES AND LIMITED CIRCUMSTANCES
          • Laboratory services under the PPO benefit program (Laboratory Network Rules and Limited Circumstances, Attachment B) are classified into three levels, as determined by the Bureau of Laboratories, and defined by the Pennsylvania Department of Health. For the PPO line of business, all level 1 and level 2 class laboratory code services are considered eligible for payment in an office or outpatient setting, when performed by any type of participating PPO physician. Laboratory services identified as level 3 or non-designated (which default to level 3) are only eligible for payment when performed by an independent or a physiological laboratory.
          • The limited circumstances of laboratory services that a participating specialist, other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are also listed in Attachment B. Refer to section B3 of the attachment for the specific provider specialties and eligible codes.
          • All other provider specialties are considered ineligible to provide laboratory services, unless otherwise identified by specialty and code in the attachment section B3.

          TO:

          LABORATORY RULES AND LIMITED CIRCUMSTANCES
          • Laboratory services under the PPO benefit program are determined by the Bureau of Laboratories, and defined by the Pennsylvania Department of Health. For the PPO line of business, all laboratory services listed in Attachment B1 of this policy are considered eligible for payment in an office or outpatient setting, when performed by any type of participating PPO provider. Laboratory services listed in Attachment B2 of this policy only eligible for payment when performed by an independent or a physiological laboratory.
          • The limited circumstances of laboratory services that a participating specialist, other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment B3 of this policy.
          • All other provider specialties are considered ineligible to provide laboratory services, unless otherwise identified by specialty and code in attachment B3 of this policy.

          Attachment B1:

          Lists all laboratory service codes that are eligible to all professional specialties in place of service office, independent lab, and outpatient hospital.

          Attachment B2:

          Lists all laboratory service codes that are only eligible to Independent or Physiological labs in place of service independent lab.

          Attachment B3:

          The lab level will be removed from the exceptions listed in this attachment. Also, The following exceptions were added:
          • Service code 87220 allowed to be reported by a dermatologist in an office place of service.
          • Service codes 85008 and 85044 allowed to be reported by a Hematology/Oncology, Medical Oncology, or Pediatric Hematology and Oncology specialist in an office place of service.
          • Service codes 83872, 89050, 89051, and 89060 allowed to be reported by an orthopedic surgeon.
          • Service code 81007 allowed to be reported by a nephrologist in an office place of service.
          • Service code 89055 allowed to be reported by a Rheumatology and Pediatric Rheumatology specialist in an office or hospital outpatient place of service.
          • Service codes 89321, 89322, 89325, 89329, 89330,89331 and 89398 allowed to be reported by a Reproductive Endocrinologist in an office and hospital outpatient place of service.
          • Service codes 89254, 89258, 89259, 89264, 89268, 89272, 89281, 89290, and 89291 allowed to be reported by a Reproductive Endocrinologist in an office place of service.
          • Service codes 81007, 81020, 89300, 89321, and 89322 allowed to be reported by a urologist in an office and hospital outpatient place of service.
          Attachment D:
          CPT codes 97810, 97811, 97813, and 97814 were removed.

        Revisions From MA00.010j:
        11/15/2016
          This policy has been identified for a CPT code update, effective 01/01/2016.

          The following CPT codes have been added to attachment B3 of this policy to be performed by a Reproductive Endocrinologist in an office place of service:

          89254, 89261

        Revisions From MA00.010i:
        10/01/2016This policy has been identified for the HCPCS code update, effective 09/30/2016.

        The following HCPCS code has been termed from Attachment C1 of this policy:
          S8032

        The following CPT codes have been removed from Attachment B3 of this policy, effective 01/01/2016. The codes are Level 2 codes and no exception is required:
          86294, 86710, 87804

        Revisions From MA00.010h:
        08/22/2016
          This policy has been identified for the HCPCS/CPT code update.
          • CPT codes 78814 and 78816 are eligible to Nuclear Medicine (specialty 046) in place of service office (30) and outpatient hospital (22), effective 09/01/2015.
          • HCPCS codes B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B5160, B4161, B4162, B4185, B5000, B5100, B5200, and J7627 are eligible to DME/Home Infusion (specialty 083), effective 03/01/2016.
          • All reported services on Attachment C1 in place of service office (30), outpatient hospital (22), or home (30), are eligible to Neuroradiology (specialty 198), effective 01/01/2016.

        Revisions From MA00.010g:
        06/10/2016
          This policy has been identified for the HCPCS/CPT code update.

          The following exception was made to CPT code 88341, effective 1/1/2015:
          88341: Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)
          Exception for 88341:
          • Pathologist (specialty 026) and Anatomic and Clinical pathologists (specialty 173) in place of service office (30) and outpatient hospital (22) when billed with modifier 26.
          • Oral and Maxillofacial Pathology, specialty 204, in the office place of service (30) and outpatient facility place of service (22) when billed with and without modifier 26.

        Revisions From MA00.010f:
        04/15/2016
          This policy has been identified for a CPT/HCPCS code update.

          HCPCS L1902, L1906, L1930, L1940, L1960, L1970, L1971, L2220, L2275, L2330, L2350, L2820, L3000, L3020, L3030, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L5000, L4396, L4360 have been added to Attachment A3 of this policy, efffective 4/15/2016.

          CPT code 88341 has been added to Attachment B3 of this policy, effective 1/1/2015.

          Specialty 173: Anatomic and Clinical was added to Attachment B3 of this policy, effective 01/01/2016.

          CPT code 91200 has been added to Attachment C2 of this policy, effective 4/15/2016.

        Revisions From MA00.010e:
        01/01/2016
          This policy has been identified for the CPT code update effective 01/01/2016.

          The following codes have been added to Attachments A1 and A2 as DME:

          E0465, E0466, E1012, A4337

          The following codes have been added to Attachments B1 and B2 as Laboratory:

          G0475, G0476, G0477, G0478, G0479, G0480, G0481, G0482, G0483, 80081, 81490, 81493, 81525, 81528, 81535, 81536, 81538, 81540, 81545, 81595, 88350, 0423T, 81162, 81170, 81218, 81219, 81272, 81273, 81276, 81311, 81314, 81412, 81432, 8143, 81434, 81437, 81438, 81442

          The following codes have been added to Attachment C1 as Radiology:

          74712, 74713, 78265, 78266, 72081, 72082, 72083, 72084, 73501, 73502, 73503, 73521, 73522, 73523, 73551, 73552, 77770, 77771, 77772, 77767, 77768, 0394T, 0395T

          In addition to being added to Attachment C1 as Radiology, the below codes will also be added to Attachment C2 with the following exception: eligible to Orthopedic Surgeon (specialty 003), Hand Surgeon (specialty 092), and Sports Medicine (specialty 121) in place of service office (30).

          72081, 72082, 72083, 72084, 73501, 73502, 73503, 73521, 73522, 73523, 73551, 73552

          In addition to being added to Attachment C1 as Radiology, the below codes will also be added to Attachment C2 with the following exception: eligible to Radiation Oncologist (specialty 052) in place of service office (30) and outpatient hospital (22).

          77770, 77771, 77772, 77767, 77768, 0394T, 0395T

          The following codes have been termed:

          72010, 72069, 72090, 73500, 73510, 73520, 73530, 73540, 73550, 77776, 77777, 77785, 77786, 82486, 82487, 82488, 82489, 82491, 82541, 82543, 82544, 83788, 88347, 0103T, A7011, E0450, E0460, E0461, E0463, E0464, S3721, S3854, S3890, G0431, G0434

        Revisions From MA00.010d:
        10/01/2015The following CPT codes have been added to Attachment C2, effective 01/01/2015:

        77306, 77307, 77316, 77317, 77318, 77385, 77386, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017

        The following CPT code has been deleted from Attachment B1, effective 01/01/2015:

        0346T

        This policy has been identified for the ICD-10 code update, effective 10/01/2015. See Attachment E.

        Revisions From MA00.010c:
        07/01/2015This policy has been identified for CPT code update, effective 07/01/2015.

        The following code has been removed from this policy:

        S8262

        The following codes have been added to this policy:

        0009M, 0010M
        • CPT codes G6001 and G6002 were removed with a retro-effective date of 01/01/2015 due to all Radiologic Guidance codes were removed from Attachment C1 & C2 on 01/01/2010 as set-up is driven by the Radiologic Guidance of a Procedure policy 00.10.36.

        Revisions From MA00.010b:
        03/01/2015Policy MA00.010a has been revised. The policy will be reissued as MA00.010b effective 04/08/2015.
        • The below radiopharmaceutical codes have been deleted from this policy. It was determined that radiopharmaceutical codes should have never been included in Network Rules:
          A4641, A4642, A9500, A9501, A9503, A9505, A9508, A9509, A9510, A9528, A9543, A9545, A9563, A9564, A9569, A9570, A9571, A9572, A9580, A9606
        • The specialty, Interventional Cardiology, is a new specialty effective 01/01/2015. The specialty was added to this policy to correspond with Cardiology.
        • The following procedure code has been added as a new exception to Cardiologist in the office place-of-service effective 12/10/2014, the change is reflected on Attachment B3:
          • 83880 was updated as a network rule exception to allow reimbursement to a Cardiologist in place of service office only.
        • The following procedure codes have been added as a new exception to Optometrist in the office place-of-service effective 11/19/2014, the change is reflected on Attachment D:
          • 97003, 97004 and 97535 were updated as a network rule exception to allow reimbursement to an Optometrist in place of service office and outpatient hospital when reported with a low vision diagnosis
        • ICD-9 Codes representing Low Vision were added to the policy in Attachment E.
        • The following procedure code was updated as a network rule exception to allow reimbursement to a Speech Therapist in place of service office and outpatient hospital, the change is reflected on Attachment D:
          • 97532: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
        Effective 10/1/14 with quarterly coding update:
        • K0901 and K0902 have been added to the DME rule, attachment A2
        • S8032 has been added to the Radiology rule, Attachment C1

        Revisions From MA00.010a:
        01/02/2015Policy MA00.010 has been identified for the January 1, 2015 annual code update. The policy will be reissued as MA00.010a.

        The following codes have been deleted in this policy:

        74291, 76645, 77082, 77305, 77310, 77315, 77326, 77327, 77328, 77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416, 77418, 80100, 80101, 80102, 80103, 80104, 80152, 80154, 80160, 80166, 80172, 80174, 80182, 80196, 80440, 82000, 82003, 82055, 82101, 82145, 82205, 82520, 82646, 82649, 82651, 82654, 82666, 82690, 82742, 82953, 82975, 82980, 83008, 83055, 83071, 83634, 83805, 83840, 83858, 83866, 83887, 83925, 84022, 84127, 87001, 87620, 87621, 87622, 88343, 88349, 0197T, A7042, A7043, G0417, G0418, G0419, G0461, G0462, L6025, L7260, L7261

        The following codes have been revised in this policy:

        77401, 77402, 77407, 77412, 80162, 80164, 80171, 80299, 81245, 82541, 82542, 82543, 82544, 84600, 86900, 86901, 86902, 86904, 86905, 86906, 87501, 87502, 87503, 87631, 87632, 87633, 88342, 88360, 88361, 88365, 88367, 88368, A4601, E0856, E0986, G0204, G0206, G0416, L7367

        The following codes have been added in this policy:

        Attachment A1/A2:

        A4459, A4602, A7048, C2624, L3981, L6026, L7259, L8696

        Attachment B1/B2:

        80163, 80165, 80300, 80301, 80302, 80303, 80304, 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80329, 80330, 80331, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368. 80369, 80370, 80371, 80372, 80373, 80374, 80375, 80376, 80377, 81246, 81288, 81313, 81410, 81411, 81415, 81416, 81417, 81420, 81425, 81426, 81427, 81430, 81431, 81435, 81436, 81440, 81445, 81450, 81455, 81460, 81465, 81470, 81471, 81519, 83006, 87505.,87506, 87507, 87623, 87624, 87625, 87806, 88341, 88344, 88364, 88366, 88369, 88373, 88374, 88377, 89337, G0464, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6043, G6044, G6045, G6046, G6047, G6048, G6049, G6050, G6051, G6052, G6053, G6054, G6055, G6056, G6057, G6058

        Attachment C1:

        76641, 76642, 77061, 77062, 77063, 77085, 77086, 77306, 77307, 77316, 77317, 77318, 77385, 77386, 77387, 91200, 93355, 93895, A9606, G0279, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017

        Revisions From MA00.010:
        01/01/2015New policy number MA00.010 issued as a result of the development of a separate book of Medicare Advantage policy. Policy's coverage position is based on Company Claim Payment policy 00.01.25 and was developed with current Medicare Advantage policy Style Guide language and formatting.

        01/01/2025
        01/31/2025
        N/A
        MA00.010
        Medical Policy Bulletin
        Medicare Advantage
        {"598": {"Id":598,"MPAttachmentLetter":"B1","Title":"Laboratory Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9458,"PolicyAttachmentPageName":"cf265c37-89a9-42ef-bab3-e643d30e4930"},"599": {"Id":599,"MPAttachmentLetter":"A3","Title":"DME Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9459,"PolicyAttachmentPageName":"40fb6d89-af18-47ba-8c17-a2a737fae494"},"600": {"Id":600,"MPAttachmentLetter":"D","Title":"Physical Medicine & Rehabilitation Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9460,"PolicyAttachmentPageName":"6be81992-9478-4375-ae52-a75da18adef5"},"601": {"Id":601,"MPAttachmentLetter":"B3","Title":"Laboratory Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":9461,"PolicyAttachmentPageName":"d10d8d3e-7f1c-4be7-9dda-d4ef52d58f05"},"602": {"Id":602,"MPAttachmentLetter":"C2","Title":"Radiology Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":9462,"PolicyAttachmentPageName":"4801dd5a-b6ef-488a-898f-9cb8b650f841"},"603": {"Id":603,"MPAttachmentLetter":"C1","Title":"Radiology Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9463,"PolicyAttachmentPageName":"97e5ea8a-f2d1-429a-ad90-71aeaa90337d"},"604": {"Id":604,"MPAttachmentLetter":"B2.2","Title":"Laboratory Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":9464,"PolicyAttachmentPageName":"985eb97c-1ace-414d-b148-9a0ae60bee4a"},"605": {"Id":605,"MPAttachmentLetter":"B2.1","Title":"Laboratory Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9465,"PolicyAttachmentPageName":"9fd38e4f-2399-4088-b896-69212cb3952c"},"606": {"Id":606,"MPAttachmentLetter":"A1","Title":"DME Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":9466,"PolicyAttachmentPageName":"b9d970ed-3938-4dbd-87de-e10ea754b107"},"607": {"Id":607,"MPAttachmentLetter":"A2","Title":"DME Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":9467,"PolicyAttachmentPageName":"6acb94dd-0398-4e8d-b083-1135a9d47e01"},}
        No
        Connect with Us

        2025 Independence Blue Cross

        Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.