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

Title:

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

RADIOLOGY NETWORK RULE AND LIMITED CIRCUMSTANCES

NETWORK RULES PROCEDURE CODE LIST

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
0042T	01-01-2003
0501T	01-01-2018
0502T	01-01-2018
0503T	01-01-2018
0504T	01-01-2018
0144T	01-01-2006	12-31-2009
0145T	01-01-2006	12-31-2009
0146T	01-01-2006	12-31-2009
0147T	01-01-2006	12-31-2009
0148T	01-01-2006	12-31-2009
0149T	01-01-2006	12-31-2009
0150T	01-01-2006	12-31-2009
0151T	01-01-2006	12-31-2009
0153T	01-01-2006	12-31-2007
0197T	01-01-2009	12-31-2014
0286T	01-01-2012	12-31-2016
0287T	01-01-2012	12-31-2016
0330T	07-01-2013
0331T	07-01-2013
0332T	07-01-2013
0346T	01-01-2014	01-01-2019
0348T	07-01-2014
0349T	07-01-2014
0350T	07-01-2014
0394T	01-01-2016
0395T	01-01-2016
0482T	01-01-2018	01-01-2020
0541T	01-01-2019
0542T	01-01-2019
0558T	07-01-2019
0633T	01-01-2021
0634T	01-01-2021
0635T	01-01-2021
0636T	01-01-2021
0637T	01-01-2021
0638T	01-01-2021
0648T	07-01-2021
0649T	07-01-2021
0689T	1-01-2022
0690T	1-01-2022
0691T	1-01-2022
0694T	1-01-2022
0697T	1-01-2022
0698T	1-01-2022
0701T	1-01-2022
0815T	1-01-2024
0857T	1-01-2024
0865T	1-01-2024
0866T	1-01-2024
54240	01-01-1984
70030	01-01-1984
70100	01-01-1984
70110	01-01-1984
70120	01-01-1984
70130	01-01-1984
70134	01-01-1984
70140	01-01-1984
70150	01-01-1984
70160	01-01-1984
70190	01-01-1984
70200	01-01-1984
70210	01-01-1984
70220	01-01-1984
70240	01-01-1984
70250	01-01-1984
70260	01-01-1984
70300	01-01-1984
70310	01-01-1984
70320	01-01-1984
70328	01-01-1984
70330	01-01-1984
70336	01-01-1989
70350	01-01-1984
70355	01-01-1984
70360	01-01-1984
70370	01-01-1984
70371	01-01-1988
70380	01-01-1984
70450	01-01-1984
70460	01-01-1984
70470	01-01-1984
70480	01-01-1984
70481	01-01-1984
70482	01-01-1984
70486	01-01-1984
70487	01-01-1984
70488	01-01-1984
70490	01-01-1984
70491	01-01-1984
70492	01-01-1984
70496	01-01-2001
70498	01-01-2001
70540	01-01-1986
70542	01-01-2001
70543	01-01-2001
70544	01-01-2001
70545	01-01-2001
70546	01-01-2001
70547	01-01-2001
70548	01-01-2001
70549	01-01-2001
70551	01-01-1986
70552	01-01-1990
70553	01-01-1992
70557	01-01-2004
70558	01-01-2004
70559	01-01-2004
71010	01-01-1984	12/31/2017
71015	01-01-1985	12/31/2017
71020	01-01-1985	12/31/2017
71021	01-01-1984	12/31/2017
71022	01-01-1984	12/31/2017
71023	01-01-1985	12/31/2017
71030	01-01-1984	12/31/2017
71034	01-01-1984	12/31/2017
71035	01-01-1982	12/31/2017
71045	01-01-2018
71046	01-01-2018
71047	01-01-2018
71048	01-01-2018
71100	01-01-1984
71101	01-01-1984
71110	01-01-1984
71111	01-01-1984
71120	01-01-1984
71130	01-01-1984
71250	01-01-1984
71260	01-01-1984
71270	01-01-1984
71275	01-01-2001
71550	01-01-1985
71551	01-01-2001
71552	01-01-2001
71555	01-01-1994
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
72125	01-01-1984
72126	01-01-1984
72127	01-01-1986
72128	01-01-1984
72129	01-01-1984
72130	01-01-1986
72131	01-01-1984
72132	01-01-1984
72133	01-01-1986
72141	01-01-1987
72142	01-01-1990
72146	01-01-1990
72147	01-01-1990
72148	01-01-1990
72149	01-01-1990
72156	01-01-1992
72157	01-01-1992
72158	01-01-1992
72159	01-01-1994
72170	01-01-1984
72190	01-01-1984
72191	01-01-2001
72192	01-01-1984
72193	01-01-1984
72194	01-01-1984
72195	01-01-2001
72196	01-01-1988
72197	01-01-2001
72198	01-01-1994
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
73200	01-01-1984
73201	01-01-1984
73202	01-01-1984
73206	01-01-2001
73218	01-01-2001
73219	01-01-2001
73220	01-01-1986
73221	01-01-1989
73222	01-01-2001
73223	01-01-2001
73225	01-01-1994
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
73530	01-01-1984	12/31/2015
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
73700	01-01-1984
73701	01-01-1984
73702	01-01-1984
73706	01-01-2001
73718	01-01-2001

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
73719	01-01-2001
73720	01-01-1986
73721	01-01-1989
73722	01-01-2001
73723	01-01-2001
73725	01-01-1994
74000	01-01-1984	12/31/2017
74010	01-01-1984	12/31/2017
74018	01-01-2018
74019	01-01-2018
74020	01-01-1984	12/31/2017
74021	01-01-2018
74022	01-01-1984
74150	01-01-1984
74160	01-01-1984
74170	01-01-1984
74174	01-01-2012
74175	01-01-2001
74176	01-01-2011
74177	01-01-2011
74178	01-01-2011
74181	01-01-1986
74182	01-01-2001
74183	01-01-2001
74185	01-01-1994
74210	01-01-1984
74220	01-01-1984
74221	01-01-2020
74230	01-01-1984
74240	01-01-1984
74241	01-01-1984	01-01-2020
74245	01-01-1984	01-01-2020
74246	01-01-1984
74247	01-01-1984	01-01-2020
74248	01-01-2020
74249	01-01-1984	01-01-2020
74250	01-01-1984
74251	01-01-1994
74260	01-01-1984	01-01-2020
74261	01-01-2010	12-31-2014
74262	01-01-2010
74263	01-01-2010
74270	01-01-1984
74280	01-01-1984
74283	01-01-1990
74290	01-01-1984
74291	01-01-1984
74400	01-01-1986
74410	01-01-1984
74415	01-01-1984
74420	01-01-1984
74710	01-01-1984	01-01-2024
74712	01-01-2016
74713	01-01-2016
74775	01-01-1985
75552	01-01-1985	12-31-2007
75553	01-01-1994	12-31-2007
75554	01-01-1994	12-31-2007
75555	01-01-1994	12-31-2007
75556	01-01-1994	12-31-2007
75557	01-01-2008
75558	01-01-2008	12-31-2009
75559	01-01-2008
75560	01-01-2008	12-31-2009
75561	01-01-2008
75562	01-01-2008	12-31-2009
75563	01-01-2008
75564	01-01-2008	12-31-2009
75565	01-01-2010
75571	01-01-2010
75572	01-01-2010
75573	01-01-2010
75574	01-01-2010
75580	01-01-2024
75635	01-01-2001
75898	01-01-1984
76000	01-01-1984
76010	01-01-1985
76014	01-01-2025
76015	01-01-2025
76016	01-01-2025
76017	01-01-2025
76018	01-01-2025
76019	01-01-2025
76098	01-01-1987
76100	01-01-1984
76101	01-01-1984	1-01-2022
76102	01-01-1984	1-01-2022
76120	01-01-1984
76125	01-01-1984
76140	01-01-1984
76145	01-01-2021
76150	01-01-1984	01-01-2011
76350	01-01-1982	01-01-2011
76376	01-01-2006
76377	01-01-2006
76380	01-01-1992
76390	01-01-1998
76496	01-01-2003
76497	01-01-2003
76498	01-01-2003
76499	01-01-1984
76506	01-01-1982
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
76536	01-01-1986
76604	01-01-1982	12-31-2014
76641	01-01-2015
76642	01-01-2015
76645	01-01-1982
76700	01-01-1982
76705	01-01-1982
76706	01-01-2017
76770	01-01-1982
76775	01-01-1982
76800	01-01-1990
76801	01-01-2003
76802	01-01-2003
76805	01-01-1982
76810	01-01-1992

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
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
76870	01-01-1983
76872	01-01-1990
76873	01-01-2000
76880	01-01-1982	01-01-2011
76881	01-01-2011
76882	01-01-2011
76885	01-01-1998
76886	01-01-1998
76970	01-01-1986	01-01-2021
76978	01-01-2019
76979	01-01-2019
76981	01-01-2019
76982	01-01-2019
76983	01-01-2019
76987	01-01-2024
76988	01-01-2024
76999	01-01-1984
77046	01-01-2019
77047	01-01-2019
77048	01-01-2019
77049	01-01-2019
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
77058	01-01-2007	01-01-2019
77059	01-01-2007	01-01-2019
77061	01-01-2015
77062	01-01-2015
77063	01-01-2015
77065	01-01-2017
77066	01-01-2017
77067	01-01-2017
77071	01-01-2007
77072	01-01-2007
77073	01-01-2007
77074	01-01-2007
77075	01-01-2007
77076	01-01-2007
77077	01-01-2007
77078	01-01-2007
77079	01-01-2007	12-31-2011
77080	01-01-2007
77081	01-01-2007
77082	01-01-2007	12-31-2014
77083	01-01-2007	12-31-2011
77084	01-01-2007
77085	01-01-2015
77086	01-01-2015
77089	1-01-2022
77090	1-01-2022
77091	1-01-2022
77092	1-01-2022
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	01-01-2014
77295	01-01-1994
77299	01-01-1984
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
77387	01-01-2015
77399	01-01-1984
77401	01-01-1991
77402	01-01-1991
77403	01-01-1991	12-31-2014
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
77417	01-01-1991
77418	01-01-2002	12-31-2014
77422	01-01-2006	12/31/2017
77423	01-01-2006
77424	01-01-2012
77425	01-01-2012
77427	01-01-2000
77431	01-01-1991
77432	01-01-1994
77469	01-01-2012
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
77799	01-01-1984

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
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
78012	01-01-2013
78013	01-01-2013
78014	01-01-2013
78015	01-01-1984
78016	01-01-1984
78018	01-01-1984
78020	01-01-1999
78070	01-01-1989
78071	01-01-2013
78072	01-01-2013
78075	01-01-1984
78099	01-01-1984
78102	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	12/31/2017
78191	01-01-1984
78195	01-01-1984
78199	01-01-1984
78201	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
78226	01-01-2012
78227	01-01-2012
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
78265	01-01-2016
78266	01-01-2016
78267	01-01-2000
78268	01-01-2000
78270	01-01-1985	01-01-2019
78271	01-01-1985	01-01-2019
78272	01-01-1984	01-01-2019
78278	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
78451	01-01-2010
78452	01-01-2010
78453	01-01-2010
78454	01-01-2010
78456	01-01-2000
78457	01-01-1984
78458	01-01-1984
78459	01-01-1996
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
78579	01-01-2012
78580	01-01-1984
78582	01-01-2012
78584	01-01-1984	12-31-2011
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
78597	01-01-2012
78598	01-01-2012
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
78635	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
78803	01-01-1988
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	01-01-2005
78815	01-01-2005
78816	01-01-2005
78890	01-01-1984	12-31-2008
78999	01-01-1984
79005	01-01-2005
79101	01-01-2005
79200	01-01-1984
79300	01-01-1984
79403	01-01-2004
79440	01-01-1984
79445	01-01-2005
79999	01-01-1982

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
91200	01-01-2015
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
93355	01-01-2015
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
93895	01-01-2015
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
A9700	01-01-2001	12-31-2008
G0130	01-01-1999
G0202	01-01-2002	12-31-2017
G0204	01-01-2002	12-31-2017
G0206	01-01-2002	12-31-2017
G0219	01-01-2002
G0237	01-01-2002
G0252	10-01-2002
G0279	01-01-2015
G0288	01-01-2003
G0365	01-01-2005	01-01-2020
G0458	01-01-2013
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
Q0092	01-01-1993
Q3001	01-01-2001
Q9958	07-01-2005
Q9959	07-01-2005
Q9960	07-01-2005
Q9961	07-01-2005
Q9962	07-01-2005
Q9963	07-01-2005
Q9964	07-01-2005
R0070	01-01-1982
R0075	01-01-1986
S8032	10-01-2014	09-30-2016
S8037	01-01-2002
S8042	04-01-2002
S8055	01-01-2002
S8080	01-01-2001
S8085	01-01-2001

Version Effective Date:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A