services requiring prior authorization - Premera Blue Cross

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestArthrodesis, combined posterior or posterolateral technique with posteriorinterbody technique including laminectomy and/or discectomy sufficient toprepare interspace (other than for decompression), single interspace and22634 segment; each additional interspa CPT‐4 History and Physical, operative report, documentation of conservative measuresArthrodesis, posterior, for spinal deformity, with or without cast; up to 6Submit History and Physical, documentation of medical necessity including22800 vertebral segmentsCPT‐4 operative reportArthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12Submit History and Physical, documentation of medical necessity including22802 vertebral segmentsCPT‐4 operative reportArthrodesis, posterior, for spinal deformity, with or without cast; 13 or moreSubmit History and Physical, documentation of medical necessity including22804 vertebral segmentsCPT‐4 operative reportArthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3Submit History and Physical, documentation of medical necessity including22808 vertebral segmentsCPT‐4 operative reportArthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7Submit History and Physical, documentation of medical necessity including22810 vertebral segmentsCPT‐4 operative reportArthrodesis, anterior, for spinal deformity, with or without cast; 8 or moreSubmit History and Physical, documentation of medical necessity including22812 vertebral segmentsCPT‐4 operative reportTotal disc arthroplasty (artificial disc), anterior approach, includingdiscectomy with end plate preparation (includes osteophytectomy for nerveroot or spinal cord decompression and microdissection), single interspace,22856 cervical CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityTotal disc arthroplasty (artificial disc), anterior approach, includingdiscectomy to prepare interspace (other than for decompression), singleRecent History and Physical, plan of care, and documentation of medical necessity.22857 interspace, lumbarCPT‐4 Review not required for FEP.Revision including replacement of total disc arthroplasty (artificial disc),22861 anterior approach, single interspace; cervical CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityRevision including replacement of total disc arthroplasty (artificial disc),Recent History and Physical, plan of care, and documentation of medical22862 anterior approach, single interspace; lumbarCPT‐4 necessity.Review not required for FEP.Removal of total disc arthroplasty (artificial disc), anterior approach, single22864 interspace; cervical CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityRemoval of total disc arthroplasty (artificial disc), anterior approach, single22865 interspace; lumbar CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessity28344 Reconstruction, toe(s); polydactyly CPT‐4 History and Physical, documentation of medical necessity, operative reportPre Operative Evaluation, History and Physical including functional impairment, and30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip CPT‐4 Operative reportRhinoplasty, primary; complete, external parts including bony pyramid,Pre Operative Evaluation, History and Physical including functional impairment, and30410 lateral and alar cartilages, and/or elevation of nasal tipCPT‐4 Operative reportPre Operative Evaluation, History and Physical including functional impairment, and30420 Rhinoplasty, primary; including major septal repair CPT‐4 Operative reportPre Operative Evaluation, History and Physical including functional impairment, and30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) CPT‐4 Operative reportPre Operative Evaluation, History and Physical including functional impairment, and30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) CPT‐4 Operative reportCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestPre Operative Evaluation, History and Physical including functional impairment, and30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) CPT‐4 Operative reportRhinoplasty for nasal deformity secondary to congenital cleft lip and/orPre Operative Evaluation, History and Physical including functional impairment, and30460 palate, including columellar lengthening; tip onlyCPT‐4 operative reportRhinoplasty for nasal deformity secondary to congenital cleft lip and/orPre Operative Evaluation, History and Physical including functional impairment, and30462 palate, including columellar lengthening; tip, septum, osteotomiesCPT‐4 operative reportRepair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wallPre Operative Evaluation, History and Physical including functional impairment, and30465 reconstruction)CPT‐4 Operative reportAblation therapy for reduction or eradication of 1 or more pulmonarytumor(s) including pleura or chest wall when involved by tumor extension,32998 percutaneous, radiofrequency, unilateral CPT‐4 Pre Operative Evaluation, History and Physical and Operative report33221 Insertion of pacemaker pulse generator only; with existing multiple leads CPT‐4 History and Physical, plan of care and documentation of medical necessityInsertion of pacing electrode, cardiac venous system, for left ventricularpacing, with attachment to previously placed pacemaker or pacingIf billed with diagnosis Heart Failure (428.0‐428.9) request History and Physical,33224 cardioverter‐defibrillator pulse generatorCPT‐4 documentation for medical necessity. Allow with other diagnosis.Insertion of pacing electrode, cardiac venous system, for left ventricularpacing, at time of insertion of pacing cardioverter‐defibrillator or pacemakerIf billed with diagnosis Heart Failure (428.0‐428.9) request History and Physical,33225 pulse generator (including upgrade to dual chamber system)CPT‐4 documentation for medical necessity. Allow with other diagnosis..Single or multiple injections of sclerosing solutions, spider veinsPre Operative Evaluation, History and Physical including functional impairment, and36468 (telangiectasia); limb or trunkCPT‐4 Operative reportSingle or multiple injections of sclerosing solutions, spider veinsPre Operative Evaluation, History and Physical including functional impairment, and36469 (telangiectasia); faceCPT‐4 Operative reportPre Operative Evaluation, History and Physical including functional impairment, and36470 Injection of sclerosing solution; single vein CPT‐4 Operative reportPre Operative Evaluation, History and Physical including functional impairment, andOperative report36471 Injection of sclerosing solution; multiple veins, same leg CPT‐4Endovenous ablation therapy of incompetent vein, extremity, inclusive of allimaging guidance and monitoring, percutaneous, radiofrequency,; first vein36475 treatedCPT‐4Endovenous ablation therapy of incompetent vein, extremity, inclusive of allimaging guidance and monitoring, percutaneous, radiofrequency; secondand subsequent veins treated in a single extremity, each through separate36476 access sitesCPT‐4Pre Operative Evaluation, History and Physical including results of Doppler studies,and Operative reportPre Operative Evaluation, History and Physical including results of Doppler studies,and Operative report36478Endovenous ablation therapy of incompetent vein, extremity, inclusive of allimaging guidance and monitoring, percutaneous, laser; first vein treated CPT‐4Pre Operative Evaluation, History and Physical including results of Doppler studies,and Operative report36479Endovenous ablation therapy of incompetent vein, extremity, inclusive of allimaging guidance and monitoring, percutaneous, laser; second andsubsequent veins treated in a single extremity, each through separate accesssitesCPT‐4Pre Operative Evaluation, History and Physical including results of Doppler studies,and Operative report36511 Therapeutic apheresis; for white blood cells CPT‐4 Pre Operative Evaluation, History and Physical and Operative report36512 Therapeutic apheresis; for red blood cells CPT‐4 Pre Operative Evaluation, History and Physical and Operative report36513 Therapeutic apheresis; for platelets CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request37204 Transcatheter occlusion or embolization CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportVascular endoscopy, surgical, with ligation of perforator veins, subfascial37500 (SEPS) CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportSubmit documentation to describe the services. Include History and Physical with37501 Unlisted vascular endoscopy procedure CPT‐4 operative report or procedure report.Ligation and division of long saphenous vein at saphenofemoral junction, or37700 distal interruptions CPT‐4 Pre Operative Evaluation, History and Physical, and Operative report37718 Ligation, division, and stripping, short saphenous vein CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportLigation, division, and stripping, long (greater) saphenous veins from37722 saphenofemoral junction to knee or below CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportLigation and division and complete stripping of long or short saphenousveins with radical excision of ulcer and skin graft and/or interruption of37735 communicating veins of lower leg, with excision of deep fascia CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportLigation of perforator veins, subfascial, radical (Linton type), including skin37760 graft, when performed, open,1 leg CPT‐4 History and physical, operative reportLigation of perforator vein(s), subfascial, open, including ultrasound37761 guidance, when performed, 1 leg CPT‐4 History and physical, operative reportPre Operative Evaluation, History and Physical, and Operative report. Review not37765 Stab phlebectomy of varicose veins, 1 extremity; 10‐20 stab incisions CPT‐4 required for FEP.Pre Operative Evaluation, History and Physical, and Operative report. Review not37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions CPT‐4 required for FEP.Ligation and division of short saphenous vein at saphenopopliteal junction37780 (separate procedure) CPT‐4 Pre Operative Evaluation, History and Physical, and Operative report37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportIf transplant approval on record: Date of Transplant If no Transplant approval:38230 Bone marrow harvesting for transplantation CPT‐4 History and Physical, Transplant evaluation, and date of transplant38232 Bone marrow harvesting for transplantation; autologous CPT‐4 History and Physical, procedure reportBone marrow or blood‐derived peripheral stem cell transplantation;If transplant approval on record: Date of Transplant If no Transplant approval:38240 allogenicCPT‐4 History and Physical, Transplant evaluation, and date of transplantBone marrow or blood‐derived peripheral stem cell transplantation;If transplant approval on record: Date of Transplant If no Transplant approval:38241 autologousCPT‐4 History and Physical, Transplant evaluation, and date of transplantBone marrow or blood‐derived peripheral stem cell transplantation;If transplant approval on record: Date of Transplant If no Transplant approval:38242 allogeneic donor lymphocyte infusionsCPT‐4 History and Physical, Transplant evaluation, and date of transplantPre Operative evaluation, History and Physical including functional impairment, and40500 Vermilionectomy (lip shave), with mucosal advancement CPT‐4 operative report41512 Tongue base suspension, permanent suture technique CPT‐4 History and Physical, Operative reportSubmucosal ablation of the tongue base, radiofrequency, 1 or more sites, per41530 session CPT‐4 History and Physical, including Sleep study results, results of CPAP trial42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) CPT‐4 History and Physical, including Sleep study results, results of CPAP trial42950 Pharyngoplasty (plastic or reconstructive operation on pharynx) CPT‐4 History and Physical, including Sleep study results, results of CPAP trial43647Laparoscopy, surgical; implantation or replacement of gastricneurostimulator electrodes, antrum CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestLaparoscopy, surgical; revision or removal of gastric neurostimulator43648 electrodes, antrum CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportImplantation or replacement of gastric neurostimulator electrodes, antrum,43881 open CPT‐4 Pre Operative Evaluation, History and Physical and Operative report43882 Revision or removal of gastric neurostimulator electrodes, antrum, open CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportLaparoscopy, surgical; ablation of renal mass lesion(s), including50542 intraoperative ultrasound guidance and monitoring, when performed CPT‐4 History and physical, operative reportAblation, one or more renal tumor(s), percutaneous, unilateral,50592 radiofrequency CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityStereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1History and Physical, including functional capacity, location, if metastatic, and61796 simple cranial lesionCPT‐4 number of lesionsStereotactic radiosurgery (particle beam, gamma ray, or linear accelerator);each additional cranial lesion, simple (List separately in addition to code forHistory and Physical, including functional capacity, location, if metastatic, and61797 primary procedure)CPT‐4 number of lesionsStereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1History and Physical, including functional capacity, location, if metastatic, and61798 complex cranial lesionCPT‐4 number of lesionsStereotactic radiosurgery (particle beam, gamma ray, or linear accelerator);each additional cranial lesion, complex (List separately in addition to codeHistory and Physical, including functional capacity, location, if metastatic, and61799 for primary procedure)CPT‐4 number of lesionsApplication of stereotactic headframe for stereotactic radiosurgery (ListHistory and Physical, including functional capacity, location, if metastatic, and61800 separately in addition to code for primary procedure)CPT‐4 number of lesionsTwist drill or burr hole(s) for implantation of neurostimulator electrodes,61850 cortical CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportCraniectomy or craniotomy for implantation of neurostimulator electrodes,61860 cerebral, cortical CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportTwist drill, burr hole, craniotomy, or craniectomy with stereotacticimplantation of neurostimulator electrode array in subcortical site without61863 use of intraoperative microelectrode recording; first array CPT‐4 Pre Operative Evaluation, History and Physical and Operative report61864618676186861885Twist drill, burr hole, craniotomy, or craniectomy with stereotacticimplantation of neurostimulator electrode array in subcortical site withoutuse of intraoperative microelectrode recording; each additional array CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportTwist drill, burr hole, craniotomy, or craniectomy with stereotacticimplantation of neurostimulator electrode array in subcortical site with useof intraoperative microelectrode recording; first array CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportTwist drill, burr hole, craniotomy, or craniectomy with stereotacticimplantation of neurostimulator electrode array in subcortical site with useof intraoperative microelectrode recording; each additional array CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportInsertion or replacement of cranial neurostimulator pulse generator orreceiver, direct or inductive coupling; with connection to a single electrodearray CPT‐4 Pre Operative Evaluation, History and Physical and Operative reportCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestInsertion or replacement of cranial neurostimulator pulse generator orreceiver, direct or inductive coupling; with connection to 2 or more electrode61886 arrays CPT‐4 Pre Operative Evaluation, History and Physical and Operative report61888 Revision or removal of cranial neurostimulator pulse generator or receiver CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63035Laminotomy (hemilaminectomy), with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedintervertebral disc; each additional interspace, cervical or lumbarCPT‐4Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, includingminimally invasive, conservative management, MRI/CT, operative report. Reviewnot required for FEP.63620Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1spinal lesionCPT‐4History and Physical, including functional capacity, location, if metastatic, andnumber of lesions63621Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator);each additional spinal lesion (List separately in addition to code for primaryprocedure)CPT‐4History and Physical, including functional capacity, location, if metastatic, andnumber of lesions63650 Percutaneous implantation of neurostimulator electrode array, epidural CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63655Laminectomy for implantation of neurostimulator electrodes, plate/paddle,epidural CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63661Removal of spinal neurostimulator electrode percutaneous array(s),including fluoroscopy, when performed CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63662Removal of spinal neurostimulator electrode plate/paddle(s) placed vialaminotomy or laminectomy, including fluoroscopy, when performed CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63663Revision including replacement, when performed, of spinal neurostimulatorelectrode percutaneous array(s), including fluoroscopy, when performed CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63664Revision including replacement, when performed, of spinal neurostimulatorelectrode plate/paddle(s) placed via laminotomy or laminectomy, includingfluoroscopy, when performed CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63685Insertion or replacement of spinal neurostimulator pulse generator orreceiver, direct or inductive coupling CPT‐4 Pre Operative Evaluation, History and Physical and Operative report63688Revision or removal of implanted spinal neurostimulator pulse generator orreceiver CPT‐4 Pre Operative Evaluation, History and Physical and Operative report64561Percutaneous implantation of neurostimulator electrodes sacral nerve(transforaminal placement) CPT‐4 Pre Operative Evaluation, History and Physical and Operative report64565 Percutaneous implantation of neurostimulator electrodes; neuromuscular CPT‐4Recent History and Physical, plan of care, and documentation of medical necessity.Review not required for FEP.64566Posterior tibial neurostimulation, percutaneous needle electrode, singletreatment, includes programming CPT‐4 History and Physical, clinical notes from ordering provider, procedure report64568Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulatorelectrode array and pulse generator CPT‐4 History and Physical, medical necessity documentation, operative report6456964570Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulatorelectrode array, including connection to existing pulse generator CPT‐4 History and Physical, medical necessity documentation, procedure reportRemoval of cranial nerve (eg, vagus nerve) neurostimulator electrode arrayand pulse generator CPT‐4 History and Physical, medical necessity documentation, procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request64575 Inserion peripheral nerve stimulator CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessity64581Incision of implantation of neurostimulator electrodes sacral nerve(transforaminal placement) CPT‐4 Pre Operative Evaluation, History and Physical and Operative report64585 Revision or removal of peripheral neurostimulator electrode array CPT‐4History and Physical indicating symptomology, and previous measures tried. Reviewnot required for FEP.64590Insertion or replacement of peripheral or gastric neurostimulator pulsegenerator or receiver, direct or inductive coupling CPT‐4 History and Physical, procedure report, conservative treatments attempted64595Revision or removal of peripheral or gastric neurostimulator pulse generatoror receiver CPT‐4 Historyr and Physical; operative report64633Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint CPT‐4 History and Physical, operative report, documentation of conservative measures64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); cervical or thoracic, each additionalfacet joint (List separately in addition to code for primary procedure) CPT‐4 History and Physical, operative report, documentation of conservative measures64635Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint CPT‐4 History and Physical, operative report, documentation of conservative measures64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facetjoint (List separately in addition to code for primary procedure) CPT‐4 History and Physical, operative report, documentation of conservative measures65756 Keratoplasty (corneal transplant); endothelial CPT‐4 Pre Operative Evaluation, History and Physical and Operative report65760 Keratomileusis CPT‐4 Pre Operative Evaluation, History and Physical and Operative report65765 Keratophakia CPT‐4 Pre Operative Evaluation, History and Physical and Operative report65767 Epikeratoplasty CPT‐4 History and physical, operative report65770 Keratoprosthesis CPT‐4 History and physical, prosthesis type, operative report65771 Radial keratotomy CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andOperative report65772 Corneal relaxing incision for correction of surgically induced astigmatism CPT‐4 Pre Operative Evaluation, History and Physical and Operative report65775 Corneal wedge resection for correction of surgically induced astigmatism CPT‐4 Pre Operative Evaluation, History and Physical and Operative report67900 Repair of brow ptosis (supraciliary, mid‐forehead or coronal approach) CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67901Repair of blepharoptosis; frontalis muscle technique with suture or othermaterial (eg, banked fascia)CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67902Repair of blepharoptosis; frontalis muscle technique with autologous fascialsling (includes obtaining fascia)CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67903Repair of blepharoptosis; (tarso) levator resection or advancement, internalapproachCPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67904Repair of blepharoptosis; (tarso) levator resection or advancement, externalapproachCPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67906Repair of blepharoptosis; superior rectus technique with fascial sling(includes obtaining fascia)CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos67908Repair of blepharoptosis; conjunctivo‐tarso‐Muller's muscle‐levatorresection (eg, Fasanella‐Servat type)CPT‐4Pre Operative Evaluation, History and Physical including functional impairment, andoperative report including photosCPT codes, descriptions and material are copyrighted by the American Medical Association. 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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestPre Operative Evaluation, History and Physical including functional impairment, and67909 Reduction of overcorrection of ptosis CPT‐4 operative report including photosPre Operative Evaluation, History and Physical including functional impairment, andoperative report including photos. Allow if billed with diagnosis codes 376.21‐67911 Correction of lid retraction CPT‐4 376.22 and 242.00‐242.01.Correction of lagophthalmos, with implantation of upper eyelid lid load (eg,Pre Operative Evaluation, History and Physical, documentation of medical necessity67912 gold weight)CPT‐4 and operative report. Review not required for FEP.Pre Operative Evaluation, History and Physical, documentation of medical necessity67950 Canthoplasty (reconstruction of canthus) CPT‐4 and operative report67961Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,canthus, or full thickness, may include preparation for skin graft or pedicleflap with adjacent tissue transfer or rearrangement; up to 1/4 of lid marginCPT‐4Pre Operative Evaluation, History and Physical, documentation of medical necessityand operative report67966Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,canthus, or full thickness, may include preparation for skin graft or pedicleflap with adjacent tissue transfer or rearrangement; over 1/4 of lid marginCPT‐469300 Otoplasty, protruding ear, with or without size reduction CPT‐4Implantation or replacement of electromagnetic bone conduction hearing69710 device in temporal boneCPT‐4Removal or repair of electromagnetic bone conduction hearing device in69711 temporal boneCPT‐4Implantation, osseointegrated implant, temporal bone, with percutaneousattachment to external speech processor/cochlear stimulator; without69714 mastoidectomyCPT‐4Implantation, osseointegrated implant, temporal bone, with percutaneousattachment to external speech processor/cochlear stimulator; with69715 mastoidectomyCPT‐4Replacement (including removal of existing device), osseointegrated implant,temporal bone, with percutaneous attachment to external speech69717 processor/cochlear stimulator; without mastoidectomyCPT‐4Replacement (including removal of existing device), osseointegrated implant,temporal bone, with percutaneous attachment to external speech69718 processor/cochlear stimulator; with mastoidectomyCPT‐469930 Cochlear device implantation, with or without mastoidectomy CPT‐470336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) CPT‐470450 Computed tomography, head or brain; without contrast material CPT‐470460 Computed tomography, head or brain; with contrast material(s) CPT‐4Pre Operative Evaluation, History and Physical, documentation of medical necessityand operative reportPre Operative Evaluation, History and Physical including functional impairment, andOperative reportPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing Impairment. Non‐covered service for FEP.Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing Impairment. Non‐covered service for FEP.Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 11 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestComputed tomography, head or brain; without contrast material, followedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70470 by contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianComputed tomography, orbit, sella, or posterior fossa or outer, middle, orOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70480 inner ear; without contrast materialCPT‐4 Physical, procedure report, name of referring physicianComputed tomography, orbit, sella, or posterior fossa or outer, middle, orOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70481 inner ear; with contrast material(s)CPT‐4 Physical, procedure report, name of referring physicianComputed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; without contrast material, followed by contrast material(s) andOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70482 further sectionsCPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70486 Computed tomography, maxillofacial area; without contrast material CPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70487 Computed tomography, maxillofacial area; with contrast material(s) CPT‐4 Physical, procedure report, name of referring physicianComputed tomography, maxillofacial area; without contrast material,Online review at www.aimspecialtyhealth.com For Prior Authorization: History and70488 followed by contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70490 Computed tomography, soft tissue neck; without contrast material CPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70491 Computed tomography, soft tissue neck; with contrast material(s) CPT‐4 Physical, procedure report, name of referring physicianComputed tomography, soft tissue neck; without contrast material followedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70492 by contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianComputed tomographic angiography, head, with contrast material(s),Online review at www.aimspecialtyhealth.com For Prior Authorization: History and70496 including noncontrast images, if performed, and image postprocessing CPT‐4 Physical, results of previous diagnostic procedure reportComputed tomographic angiography, neck, with contrast material(s),Online review at www.aimspecialtyhealth.com For Prior Authorization: History and70498 including noncontrast images, if performed, and image postprocessing CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, orbit, face, and/or neck; withoutOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70540 contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, orbit, face, and/or neck; withOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70542 contrast material(s)CPT‐4 Physical, procedure report, name of referring physician70543Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; withoutcontrast material(s), followed by contrast material(s) and further sequencesCPT‐470544 MRA head; w/o contrast CPT‐470545 MRA head; with contrast CPT‐4Magnetic resonance angiography, head; without contrast material(s),70546 followed by contrast material(s) and further sequencesCPT‐470547 Magnetic resonance angiography, neck; without contrast material(s) CPT‐470548 Magnetic resonance angiography, neck; with contrast material(s) CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 12 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestMagnetic resonance angiography, neck; without contrast material(s),Online review at www.aimspecialtyhealth.com For Prior Authorization: History and70549 followed by contrast material(s) and further sequencesCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, brain (including brain stem);Online review at www.aimspecialtyhealth.com For Prior Authorization: History and70551 without contrast materialCPT‐4 Physical, procedure report, name of referring physicianMagnetic resonance (eg, proton) imaging, brain (including brain stem); withOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70552 contrast material(s)CPT‐4 Physical, procedure report, name of referring physicianMagnetic resonance (eg, proton) imaging, brain (including brain stem);without contrast material, followed by contrast material(s) and furtherOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and70553 sequencesCPT‐4 Physical, procedure report, name of referring physician70554Magnetic resonance imaging, brain, functional MRI; including test selectionand administration of repetitive body part movement and/or visualstimulation, not requiring physician or psychologist administrationCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service70555Magnetic resonance imaging, brain, functional MRI; requiring physician orpsychologist administration of entire neurofunctional testingCPT‐471250 Computed tomography, thorax; without contrast material CPT‐471260 Computed tomography, thorax; with contrast material(s) CPT‐4Computed tomography, thorax; without contrast material, followed by71270 contrast material(s) and further sectionsCPT‐4Computed tomographic angiography, chest (noncoronary), with contrastmaterial(s), including noncontrast images, if performed, and image71275 postprocessingCPT‐4Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar71550 and mediastinal lymphadenopathy); without contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar71551 and mediastinal lymphadenopathy); with contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilarand mediastinal lymphadenopathy); without contrast material(s), followed71552 by contrast material(s) and further sequencesCPT‐471555 MRA chest; with or w/o contrast CPT‐472125 Computed tomography, cervical spine; without contrast material CPT‐472126 Computed tomography, cervical spine; with contrast material CPT‐4Computed tomography, cervical spine; without contrast material, followed72127 by contrast material(s) and further sectionsCPT‐472128 Computed tomography, thoracic spine; without contrast material CPT‐472129 Computed tomography, thoracic spine; with contrast material CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed serviceOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical , results of previous diagnositic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 13 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestComputed tomography, thoracic spine; without contrast material, followedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72130 by contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72131 Computed tomography, lumbar spine; without contrast material CPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72132 Computed tomography, lumbar spine; with contrast material CPT‐4 Physical, procedure report, name of referring physicianComputed tomography, lumbar spine; without contrast material, followedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72133 by contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianMagnetic resonance (eg, proton) imaging, spinal canal and contents, cervical;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72141 without contrast materialCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents, cervical;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72142 with contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents,Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72146 thoracic; without contrast materialCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents,Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72147 thoracic; with contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72148 without contrast materialCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72149 with contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, spinal canal and contents, withoutcontrast material, followed by contrast material(s) and further sequences;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and72156 cervicalCPT‐4 Physical, results of previous diagnostic procedure report72157721587215972191Magnetic resonance (eg, proton) imaging, spinal canal and contents, withoutcontrast material, followed by contrast material(s) and further sequences;thoracicMagnetic resonance (eg, proton) imaging, spinal canal and contents, withoutcontrast material, followed by contrast material(s) and further sequences;lumbarMagnetic resonance angiography, spinal canal and contents, with or withoutcontrast material(s)Computed tomographic angiography, pelvis, with contrast material(s),including noncontrast images, if performed, and image postprocessingCPT‐4CPT‐4CPT‐4CPT‐472192 Computed tomography, pelvis; without contrast material CPT‐472193 Computed tomography, pelvis; with contrast material(s) CPT‐4Computed tomography, pelvis; without contrast material, followed by72194 contrast material(s) and further sectionsCPT‐4Magnetic resonance (eg, proton) imaging, pelvis; without contrast72195 material(s)CPT‐472196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 14 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestMagnetic resonance (eg, proton) imaging, pelvis; without contrastOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72197 material(s), followed by contrast material(s) and further sequencesCPT‐4 Physical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) CPT‐4 Physical, results of previous diagnostic procedure reportRadiological supervision and interpretation, percutaneous vertebroplasty orvertebral augmentation including cavity creation, per vertebral body; under72291 fluoroscopic guidance CPT‐4 History and physical, operative reportRadiological supervision and interpretation, percutaneous vertebroplasty orvertebral augmentation including cavity creation, per vertebral body; under72292 CT guidance CPT‐4 History and physical, operative reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73200 Computed tomography, upper extremity; without contrast material CPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73201 Computed tomography, upper extremity; with contrast material(s) CPT‐4Computed tomography, upper extremity; without contrast material,73202 followed by contrast material(s) and further sectionsCPT‐4Computed tomographic angiography, upper extremity, with contrastmaterial(s), including noncontrast images, if performed, and image73206 postprocessingCPT‐4Magnetic resonance (eg, proton) imaging, upper extremity, other than joint;73218 without contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, upper extremity, other than joint;73219 with contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, upper extremity, other than joint;without contrast material(s), followed by contrast material(s) and further73220 sequencesCPT‐4Magnetic resonance (eg, proton) imaging, any joint of upper extremity;73221 without contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with73222 contrast material(s)CPT‐4Magnetic resonance (eg, proton) imaging, any joint of upper extremity;without contrast material(s), followed by contrast material(s) and further73223 sequencesCPT‐4Magnetic resonance angiography, upper extremity, with or without contrast73225 material(s)CPT‐473700 Computed tomography, lower extremity; without contrast material CPT‐473701 Computed tomography, lower extremity; with contrast material(s) CPT‐4Computed tomography, lower extremity; without contrast material, followed73702 by contrast material(s) and further sectionsCPT‐4Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical , results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, name of referring physicianCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 15 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestComputed tomographic angiography, lower extremity, with contrastmaterial(s), including noncontrast images, if performed, and imageOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73706 postprocessingCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, lower extremity other than joint;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and73718 without contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, lower extremity other than joint;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and73719 with contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, lower extremity other than joint;without contrast material(s), followed by contrast material(s) and furtherOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73720 sequencesCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, any joint of lower extremity;Online review at www.aimspecialtyhealth.com For Prior Authorization: History and73721 without contrast materialCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, any joint of lower extremity; withOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73722 contrast material(s)CPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance (eg, proton) imaging, any joint of lower extremity;without contrast material(s), followed by contrast material(s) and furtherOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73723 sequencesCPT‐4 Physical, results of previous diagnostic procedure reportMagnetic resonance angiography, lower extremity, with or without contrastOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and73725 material(s)CPT‐4 Physical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74150 Computed tomography, abdomen; without contrast material CPT‐4 Physical, procedure report, name of referring physicianOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74160 Computed tomography, abdomen; with contrast material(s) CPT‐4 Physical, procedure report, name of referring physicianComputed tomography, abdomen; without contrast material, followed byOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74170 contrast material(s) and further sectionsCPT‐4 Physical, procedure report, name of referring physicianComputed tomographic angiography, abdomen and pelvis (New code as ofOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74174 01/01/2012) CPT‐4 Physical, results of previous diagnostic procedure reportComputed tomographic angiography, abdomen, with contrast material(s),Online review at www.aimspecialtyhealth.com For Prior Authorization: History and74175 including noncontrast images, if performed, and image postprocessing CPT‐4 Physical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74176 Computed tomography, abdomen and pelvis; without contrast material CPT‐4 Physical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure report74177 Computed tomography, abdomen and pelvis; with contrast material(s) CPT‐4Computed tomography, abdomen and pelvis; without contrast material inone or both body regions, followed by contrast material(s) and further74178 sections in one or both body regionsCPT‐4Magnetic resonance (eg, proton) imaging, abdomen; without contrast74181 material(s)CPT‐4Magnetic resonance (eg, proton) imaging, abdomen; with contrast74182 material(s)CPT‐4Magnetic resonance (eg, proton) imaging, abdomen; without contrast74183 material(s), followed by with contrast material(s) and further sequences CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 16 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestMagnetic resonance angiography, abdomen, with or without contrastOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and74185 material(s)CPT‐4 Physical, results of previous diagnostic procedure report7426174262Computed tomographic (CT) colonography, diagnostic, including imagepostprocessing; without contrast materialComputed tomographic (CT) colonography, diagnostic, including imagepostprocessing; with contrast material(s) including non‐contrast images, ifperformedCPT‐4CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed serviceOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service74263Computed tomographic (CT) colonography, screening, including imagepostprocessingCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service75557Cardiac magnetic resonance imaging for morphology and function withoutcontrast material;CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcome75559Cardiac magnetic resonance imaging for morphology and function withoutcontrast material; with stress imagingCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcome75561Cardiac magnetic resonance imaging for morphology and function withoutcontrast material(s), followed by contrast material(s) and further sequences; CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcome75563Cardiac magnetic resonance imaging for morphology and function withoutcontrast material(s), followed by contrast material(s) and further sequences;with stress imagingCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcome75571Computed tomography, heart, without contrast material, with quantitativeevaluation of coronary calciumCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, office notes from ordering physician for visits relating to billed service andresults of testing performed75572Computed tomography, heart, with contrast material, for evaluation ofcardiac structure and morphology (including 3D image postprocessing,assessment of cardiac function, and evaluation of venous structures, ifperformed)CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service andresults of testing performed.75573Computed tomography, heart, with contrast material, for evaluation ofcardiac structure and morphology in the setting of congenital heart disease(including 3D image postprocessing, assessment of LV cardiac function, RVstructure and function)CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service andresults of testing performed75574Computed tomographic angiography, heart, coronary arteries and bypassgrafts (when present), with contrast material, including 3D imagepostprocessing (including evaluation of cardiac structure and morphology,assessment of cardiac function)CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service75635Computed tomographic angiography, abdominal aorta and bilateraliliofemoral lower extremity runoff, with contrast material(s), includingnoncontrast images, if performed, and image postprocessingCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure report75894 Transcatheter embolization CPT‐4 History and Physical, including prior treatment regimensCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 17 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request76390 Magnetic resonance spectroscopy CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service77058Magnetic resonance imaging, breast, without and/or with contrastmaterial(s); unilateralCPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed service7705977078Magnetic resonance imaging, breast, without and/or with contrastmaterial(s); bilateralComputed tomography, bone mineral density study, 1 or more sites; axialskeleton (eg, hips, pelvis, spine)CPT‐4CPT‐477084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office notes from ordering physician for visits relating to billed serviceOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, current drug regimenOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure report77301Intensity modulated radiotherapy plan including dose‐volume histograms fortarget and critical structure partial tolerance specificationsCPT‐4Submit History and Physical, documentation of medical necessity. Allow if diagnosiscode(s) is any of 154.2‐154.3,140.0‐149.9,160.0, 160.2‐160.5,161.0‐161.97733877371773727737377418Multi‐leaf collimator (MLC) device(s) for intensity modulated radiationtherapy (IMRT), design and construction per IMRT planRadiation treatment delivery, stereotactic radiosurgery (SRS), completecourse of treatment of cerebral lesion(s) consisting of 1 session; multisourceCobalt 60 based or more lesions, including image guidance, entire course notto exceed 5 fractionsRadiation treatment delivery, stereotactic radiosurgery (SRS), completecourse of treatment of cranial lesion(s) consisting of 1 session; linearaccelerator basedStereotactic body radiation therapy, treatment delivery, per fraction to 1 ormore lesions, including image guidance, entire course not to exceed 5fractionsIntensity modulated treatment delivery single or multiple fields/arcs vianarrow spatially and temporally modulated beams (eg binary dynamic MLC)per treatment sessionCPT‐4CPT‐4CPT‐4CPT‐4CPT‐477424 Intraoperative radiation treatment delivery, x‐ray, single treatment session CPT‐4Intraoperative radiation treatment delivery, electrons, single treatment77425 sessionCPT‐4Stereotactic radiation treatment management of cranial lesion(s) (complete77432 course of treatment consisting of 1 session)CPT‐4Stereotactic body radiation therapy, treatment management, per treatmentcourse, to 1 or more lesions, including image guidance, entire course not to77435 exceed 5 fractionsCPT‐477469 Intraoperative radiation treatment management CPT‐4Submit History and Physical, documentation of medical necessity. Allow if diagnosiscode(s) is any of 154.2‐154.3,140.0‐149.9,160.0, 160.2‐160.5,161.0‐161.9History and Physical, including functional capacity, if metastatic, and number oflesionsHistory and Physical, including functional capacity, if metastatic, and number oflesionsHistory and Physical, including functional capacity,location, if metastatic, andnumber of lesionsSubmit History and Physical, documentation of medical necessity. Allow if diagnosiscode(s) is any of 154.2‐154.3,140.0‐149.9,160.0, 160.2‐160.5,161.0‐161.9History and Physical, treatment plan, documentation of medical necessity. Allow ifdiagnosis is rectal cancer (154.1)History and Physical, treatment plan, documentation of medical necessity. Allow ifdiagnosis is rectal cancer (154.1)History and Physical, including functional capacity, if metastatic, and number oflesionsHistory and Physical, including functional capacity,location, if metastatic, andnumber of lesionsHistory and Physical, treatment plan, documentation of medical necessity. Allow ifdiagnosis is rectal cancer (154.1)CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 18 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request77520 Proton treatment delivery; simple, without compensation CPT‐4 History and Physical, treatment plan. Allow if group #9000000 Alyeska77522 Proton treatment delivery; simple, with compensation CPT‐4 History and Physical, treatment plan. Allow if group #9000000 Alyeska77523 Proton treatment delivery; intermediate CPT‐4 History and Physical, treatment plan. Allow if group #9000000 AlyeskaHistory and Physical indicating why treatment is being done. Allow if group#9000000 Alyeska77525 Proton treatment delivery; complex CPT‐4Myocardial perfusion imaging, tomographic (SPECT) (including attenuationcorrection, qualitative or quantitative wall motion, ejection fraction by firstpass or gated technique, additional quantification, when performed); single78451 study, at rest or stress (CPT‐4Myocardial perfusion imaging, tomographic (SPECT) (including attenuationcorrection, qualitative or quantitative wall motion, ejection fraction by firstpass or gated technique, additional quantification, when performed);78452 multiple studies, at rest and/orCPT‐4Myocardial perfusion imaging, planar (including qualitative or quantitativewall motion, ejection fraction by first pass or gated technique, additionalquantification, when performed); single study, at rest or stress (exercise or78453 pharmacologic)CPT‐4Myocardial perfusion imaging, planar (including qualitative or quantitativewall motion, ejection fraction by first pass or gated technique, additionalquantification, when performed); multiple studies, at rest and/or stress78454 (exercise or pharmacologic) anCPT‐4Myocardial imaging, positron emission tomography (PET), metabolic78459 evaluationCPT‐478466 Myocardial imaging, infarct avid, planar; qualitative or quantitative CPT‐47846878469784727847378481Myocardial imaging, infarct avid, planar; with ejection fraction by first passtechniqueMyocardial imaging, infarct avid, planar; tomographic SPECT with or withoutquantificationCardiac blood pool imaging, gated equilibrium; planar, single study at rest orstress (exercise and/or pharmacologic), wall motion study plus ejectionfraction, with or without additional quantitative processingCardiac blood pool imaging, gated equilibrium; multiple studies, wall motionstudy plus ejection fraction, at rest and stress (exercise and/orpharmacologic), with or without additional quantificationCardiac blood pool imaging (planar), first pass technique; single study, at restor with stress (exercise and/or pharmacologic), wall motion study plusejection fraction, with or without quantificationCPT‐4CPT‐4CPT‐4CPT‐4CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical , results of previous diagnositic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 19 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestCardiac blood pool imaging (planar), first pass technique; multiple studies, atOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andrest and with stress (exercise and/ or pharmacologic), wall motion study plusPhysical, procedure report, prior cardiac imaging procedure performed and78483 ejection fraction, with or without quantificationCPT‐4 outcomeMyocardial imaging, positron emission tomography (PET), perfusion; singleOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and784917849278494study at rest or stressMyocardial imaging, positron emission tomography (PET), perfusion;multiple studies at rest and/or stressCardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motionstudy plus ejection fraction, with or without quantitative processingCPT‐4CPT‐4CPT‐478608 Brain imaging, positron emission tomography (PET); metabolic evaluation CPT‐478609 Brain imaging, positron emission tomography (PET); perfusion evaluation CPT‐478811Tumor imaging, positron emission tomography (PET); limited area (e.g., leg,chest, head/neck)CPT‐478812 Tumor imaging, positron emission tomography (PET); skull base to mid‐thigh CPT‐478813 Tumor imaging, positron emission tomography (PET); whole body CPT‐4788147881578816Tumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: limited areas (e.g., leg, chest, head/neck)Tumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: skull base to mid‐thighTumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: whole bodyCPT‐4CPT‐4CPT‐488241 Thawing and expansion of frozen cells, each aliquot CPT‐4Physical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office Notes from ordering Physician for visits related to the billed serviceand results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office Notes from ordering Physician for visits related to the billed serviceand results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 20 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestRespiratory syncytial virus, monoclonal antibody, recombinant, forAge or gestational age, History of respiratory problems, Current medical treatment,90378 intramuscular use, 50 mg, eachCPT‐4 if any risk factorsOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and93303 Transthoracic echocardiography for congenital cardiac anomalies; complete CPT‐4 Physical, copy of procedure reportTransthoracic echocardiography for congenital cardiac anomalies; follow‐upOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and93304 or limited studyCPT‐4 Physical, copy of procedure report9330693307Echocardiography, transthoracic, real‐time with image documentation (2D),includes M‐mode recording, when performed, complete, with spectralDoppler echocardiography, and with color flow Doppler echocardiographyEchocardiography, transthoracic, real‐time with image documentation (2D),includes M‐mode recording, when performed, complete, without spectral orcolor Doppler echocardiographyCPT‐4CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure report933089331293313933149331593316933179335093351Echocardiography, transthoracic, real‐time with image documentation (2D),includes M‐mode recording, when performed, follow‐up or limited studyEchocardiography, transesophageal, real‐time with image documentation(2D) (with or without M‐mode recording); including probe placement, imageacquisition, interpretation and reportEchocardiography, transesophageal, real‐time with image documentation(2D) (with or without M‐mode recording); placement of transesophagealprobe onlyEchocardiography, transesophageal, real‐time with image documentation(2D) (with or without M‐mode recording); image acquisition, interpretationand report onlyTransesophageal echocardiography for congenital cardiac anomalies;including probe placement, image acquisition, interpretation and reportTransesophageal echocardiography for congenital cardiac anomalies;placement of transesophageal probe onlyTransesophageal echocardiography for congenital cardiac anomalies; imageacquisition, interpretation and report onlyEchocardiography, transthoracic, real‐time with image documentation (2D),includes M‐mode recording, when performed, during rest and cardiovascularstress test using treadmill, bicycle exercise and/or pharmacologically inducedstress, with interpretation and report;Echocardiography, transthoracic, real‐time with image documentation (2D),includes M‐mode recording, when performed, during rest and cardiovascularstress test using treadmill, bicycle exercise and/or pharmacologically inducedstress, with interpretation and reportCPT‐4CPT‐4CPT‐4CPT‐4CPT‐4CPT‐4CPT‐4CPT‐4CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, copy of procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 21 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request9580795808958109581195971991830073T0092T0095T0098T0163TSleep study, simultaneous recording of ventilation, respiratory effort, ECG orheart rate, and oxygen saturation, attended by a technologistPolysomnography; sleep staging with 1‐3 additional parameters of sleep,attended by a technologistPolysomnography; sleep staging with 4 or more additional parameters ofsleep, attended by a technologistPolysomnography; sleep staging with 4 or more additional parameters ofsleep, with initiation of continuous positive airway pressure therapy orbilevel ventilation, attended by a technologistElectronic analysis of implanted neurostimulator pulse generator system;simple spinal cord, or peripheral (ie, peripheral nerve, autonomic nerve,neuromuscular) neurostimulator pulse generator/transmitter, withCPT‐4CPT‐4CPT‐4CPT‐4Submit History and Physical, medical necessity documentation, procedure report.No review needed for children age

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestRemoval of total disc arthroplasty, anterior approach, lumbar, eachadditional interspace (List separately in addition to code for primary0164T procedure CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityRevision of total disc arthroplasty (artificial disc),, anterior approach, lumbar,0165T each additional interspace CPT‐4 Recent History and Physical, plan of care, and documentation of medical necessityStereotactic placement of infusion catheter(s) in the brain for delivery oftherapeutic agent(s), including computerized stereotactic planning and burr0169T hole(s) CPT‐4 Pre Operative Evaluation, History and Physical, Operative report, and plan of careInsertion of posterior spinous process distraction device (including necessaryremoval of bone or ligament for insertion and imaging guidance), lumbar;0171T single level CPT‐4 History and Physical, Operative reportInsertion of posterior spinous process distraction device (including necessaryremoval of bone or ligament for insertion and imaging guidance), lumbar;each additional level (List separately in addition to code for primary0172T procedure) CPT‐4 History and Physical, Operative reportArthrodesis, pre‐sacral interbody technique, including instrumentation,imaging (when performed), and discectomy to prepare interspace, lumbar;0195T single interspace CPT‐4 History and Physical with procedure reportArthrodesis, pre‐sacral interbody technique, including instrumentation,imaging (when performed), and discectomy to prepare interspace, lumbar;each additional interspace (List separately in addition to code for primary0196T procedure) CPT‐4 History and Physical with procedure reportPercutaneous sacral augmentation (sacroplasty), unilateral injection(s),including the use of a balloon or mechanical device, when used, 1 or more0200T needles CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportPercutaneous sacral augmentation (sacroplasty), bilateral injections,including the use of a balloon or mechanical device, when used, 2 or more0201T needles CPT‐4 Pre Operative Evaluation, History and Physical, and Operative reportPosterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement)including facetectomy, laminectomy, foraminotomy and vertebral columnfixation, with or without injection of bone cement, including fluoroscopy,0202T single level, lumbar spine CPT‐4 Submit History and Physical, documentation of medical necessity, operative reportHigh frequency chest wall oscillation system vest, replacement for use withLetter of Medical Necessity including length of time equipment needed,functionalA7025 patient‐owned equipment, eachHCPC status if applicable and description of medical conditionHigh frequency chest wall oscillation system hose, replacement for use withLetter of Medical Necessity including length of time equipment needed,functionalA7026 patient‐owned equipment, eachHCPC status if applicable and description of medical conditionYttrium Y‐90 ibritumomab tiuxetan, therapeutic, per treatment dose, up toA9543 40 millicuries HCPC History and Physical, plan of care and procedure reportA9545 Iodine I‐131 tositumomab, therapeutic, per treatment dose HCPC History and Physical, plan of care and procedure reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 23 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8010 Limited orthodontic treatment of the primary dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8020 Limited orthodontic treatment of the transitional dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8030 Limited orthodontic treatment of the adolescent dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8040 Limited orthodontic treatment of the adult dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8050 Interceptive orthodontic treatment of the primary dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8060 Interceptive orthodontic treatment of the transitional dentition CDT • Diagnostic casts/study modelsCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 24 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8070 Comprehensive orthodontic treatment of the transitional dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8080 Comprehensive orthodontic treatment of the adolescent dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8090 Comprehensive orthodontic treatment of the adult dentition CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8210 Removable appliance therapy CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8220 Fixed appliance therapy CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8660 Pre‐orthodontic treatment visit CDT • Diagnostic casts/study modelsCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 25 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8670 Periodic orthodontic treatment visit (as part of contract) CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐raysOrthodontic retention (removal of appliances, consturction and placement• Oral facial imagesD8680 of retainer(s))CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8690 Orthodontic treatment (alternative billing to a contract fee) CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8691 Repair of orthodontic appliance CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8692 Replacement of lost or broken retainer CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8693 Rebonding or recementing of fixed retainers CDT • Diagnostic casts/study modelsCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 26 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8694 Repair of fixed retainers, includes reattachment CDTDiagnostic casts/study models• Diagnosis, history and physical documenting congenital anomaly• Treatment plan, including duration of treatment• Panoramic x‐rayOther recommended documentation:• Cephalometric x‐rays• Oral facial imagesD8999 Unspecified Orthodontic Procedure CDT • Diagnostic casts/study modelsLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0171 Commode chair with integrated seat lift mechanism, nonelectric, any type HCPC requiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0193 Powered air flotation bed (low air loss therapy) HCPC requiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0194 Air fluidized bed HCPC requiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0250 Hospital bed, fixed height, with any type side rails, with mattress HCPC requiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0251 Hospital bed, fixed height, with any type side rails, without mattress HCPC requiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0255 Hospital bed, variable height, hi‐lo, with any type side rails, with mattress HCPC requiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0256 Hospital bed, variable height, hi‐lo, with any type side rails, without mattress HCPC requiring use of special bed; including mobility statusHospital bed, semi‐electric (head and foot adjustment), with any type sideLetter of medical necessity including mobility status and anticipated length of timeE0260 rails, with mattressHCPC patient will require the equipment. No review needed if Rental.Hospital bed, semi‐electric (head and foot adjustment), with any type sideLetter of medical necessity including mobility status and anticipated length of timeE0261 rails, without mattressHCPC patient will require the equipment. No review needed if Rental.Hospital bed, total electric (head, foot, and height adjustments), with anyLetter of medical necessity including mobility status and anticipated length of timeE0265 type side rails, with mattressHCPC patient will require the equipment. No review needed if Rental.Hospital bed, total electric (head, foot, and height adjustments), with anyLetter of medical necessity including mobility status and anticipated length of timeE0266 type side rails, without mattressHCPC patient will require the equipment. No review needed if Rental.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 27 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE0270Hospital bed, institutional type includes: oscillating ,circulating, and strykerframe, with mattressHCPCE0277 Powered pressure‐reducing air mattress HCPCE0290 Hospital bed, fixed height, without side rails, with mattress HCPCE0291 Hospital bed, fixed height, without side rails, without mattress HCPCE0292 Hospital bed, variable height, hi‐lo, without side rails, with mattress HCPCE0293 Hospital bed, variable height, hi‐lo, without side rails, without mattress HCPCHospital bed, semi‐electric (head and foot adjustment), without side rails,E0294 with mattressHCPCHospital bed, semi‐electric (head and foot adjustment), without side rails,E0295 without mattressHCPCHospital bed, total electric (head, foot, and height adjustments), withoutE0296 side rails, with mattressHCPCHospital bed, total electric (head, foot, and height adjustments), withoutE0297 side rails, without mattressHCPCE0300 Pediatric crib, hospital grade, fully enclosed HCPCHospital bed, heavy‐duty, extra wide, with weight capacity greater than 350pounds, but less than or equal to 600 pounds, with any type side rails,E0301 without mattressHCPCE0302E0303E0304Hospital bed, extra heavy duty, extra wide, with weight capacity greater than600 pounds, with any type side rails, without mattress HCPCHospital bed, heavy‐duty, extra wide, with weight capacity greater than 350pounds, but less than or equal to 600 pounds, with any type side rails, withmattressHCPCHospital bed, extra heavy‐duty, extra wide, with weight capacity greaterthan 600 pounds, with any type side rails, with mattressHCPCLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity including mobility status and anticipated length of timepatient will require the equipment. No review needed if Rental.Letter of medical necessity including mobility status and anticipated length of timepatient will require the equipment. No review needed if Rental.Letter of medical necessity including mobility status and anticipated length of timepatient will require the equipment. No review needed if Rental.Letter of medical necessity including mobility status and anticipated length of timepatient will require the equipment. No review needed if Rental.Letter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 28 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of special bed; including mobility statusE0316 Safety enclosure frame/canopy for use with hospital bed, any type HCPCHospital bed, pediatric, manual, 360 degree side enclosures, top ofheadboard, footboard and side rails up to 24 inches above the spring,Letter of medical necessity including mobility status and anticipated length of timeE0328 includes mattressHCPC patient will require the equipment. No review needed if Rental.Hospital bed, pediatric, electric or semi‐electric, 360 degree side enclosures,top of headboard, footboard and side rails up to 24 inches above the spring,Letter of medical necessity including mobility status and anticipated length of timeE0329 includes mattressHCPC patient will require the equipment. No review needed if Rental.Letter of medical necessity containing the following information: Anticipated lengthNonpowered advanced pressure reducing overlay for mattress, standardof time patient will require the equipment, Description of medical conditionE0371 mattress length and widthHCPC requiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0372 Powered air overlay for mattress, standard mattress length and width HCPC requiring use of this equipment including mobility statusE0373 Nonpowered advanced pressure reducing mattress HCPC History & Physical, including size, depth, location of decubitiLetter of Medical Necessity including length of time equipment needed,functionalE0484 Oscillatory positive expiratory pressure device, nonelectric, any type, each HCPC status if applicable and description of medical conditionLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0621 Sling or seat, patient lift, canvas or nylon HCPC requiring use of this equipment including mobility statusE0625 Patient lift, bathroom or toilet, not otherwise classified HCPCE0627 Seat lift mechanism incorporated into a combination lift‐chair mechanism HCPCE0629E0630E0637E0638E0641E0642Separate seat lift mechanism for use with patient‐owned furniture,nonelectricPatient lift; hydraulic or mechanical, includes any seat, sling, strap(s), orpad(s)Combination sit and stand system, any size, with seat lift feature, with orwithout wheelsHCPCHCPCHCPCLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility statusStanding frame system, one position (e.g., upright, supine or prone stander),any size including pediatric, with or without wheelsHCPCStanding frame system, multi‐position (e.g., three‐way stander,), any sizeincluding pediatric, with or without wheels HCPC Letter of medical necessity, including condition being treated.Standing frame system, mobile (dynamic stander), any size includingpediatric HCPC Letter of medical necessity, including condition being treatedCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 29 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status. Allow with diagnosis codeE0650 Pneumatic compressor, nonsegmental home model HCPC 457.0Letter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionPneumatic compressor, segmental home model without calibrated gradientrequiring use of this equipment including mobility status. Allow with diagnosis codeE0651 pressureHCPC 457.0Pneumatic compressor, segmental home model with calibrated gradientE0652 pressure HCPC Letter of medical necessity, including condition being treated.Letter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk HCPC requiring use of special bed; including mobility statusLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionE0657 Segmental pneumatic appliance for use with pneumatic compressor, chest HCPC requiring use of special bed; including mobility statusE0673 Segmental gradient pressure pneumatic appliance, half leg HCPC Letter of medical necessity, including condition being treatedPneumatic compression device, high pressure, rapid inflation/deflation cycle,History and Physical including comorbidities, previously tried clinical interventionsE0675 for arterial insufficiency (unilateral or bilateral system)HCPC and operative report if any availableHistory and Physical including comorbidities, previously tried clinical interventionsE0745 Neuromuscular stimulator, electronic shock unit HCPC and operative report if any availableTranscutaneous electrical joint stimulation device system, includes allLetter of Medical Necessity including length of time equipment needed,functionalE0762 accessoriesHCPC status if applicable and description of medical conditionFunctional neuromuscular stimulator, transcutaneous stimulation of musclesof ambulation with computer control, used for walking by spinal cordE0764 injured, entire system, after completion of training program HCPC History and physical, plan of careFDA approved nerve stimulator, with replaceable batteries, for treatment ofHistory and Physical including comorbidities, previously tried clinical interventionsE0765 nausea and vomitingHCPC and operative report if any availableE0770E0912Functional electrical stimulator, transcutaneous stimulation of nerve, and/ormuscle groups, any type, complete system, not otherwise specifiedHCPCTrapeze bar, heavy‐duty, for patient weight capacity greater than 250pounds, freestanding, complete with grab bar HCPC History and Physical, documentation of medical necessity.E0950 Wheelchair accessory, tray, each HCPCWheelchair accessory, headrest, cushioned, any type, including fixedE0955 mounting hardware, eachHCPCE0983Manual wheelchair accessory, power add‐on to convert manual wheelchairto motorized wheelchair, joystick controlHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical condition. Include invoice of cost foritem.Letter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.Diagnosis, Abilities and limitations as they relate to the equipment (e.g., degree ofindependence/ dependence, frequency and nature of the activities the patientperforms, duration of medical condition, Past experience if any using similarequipment, Evaluation of upper extremity strength and Documented inability topropel a manual chairCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 30 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestDiagnosis, Abilities and limitations as they relate to the equipment (e.g., degree ofindependence/ dependence, frequency and nature of the activities the patientperforms, duration of medical condition, Past experience if any using similarequipment, Evaluation of upper extremity strength and Documented inability toPower add‐on to convert manual wheelchair to motorized wheelchair, tillerpropel a manual chairE0984 cotnrolHCPCE0985 Wheelchair accessory, seat lift mechanism HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE0986 Manual wheelchair accessory, push activated power assist, each HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1002 Power seating system, tilt only HCPC Letter of medical Necessity supporting need for the wheelchair accessoryWheelchair accessory, power seating system, recline only, without shearE1003 reduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryWheelchair accessory, power seating system, recline only, with mechanicalE1004 shear reduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryWheelchair accessory, power seatng System, recline only, with power shearE1005 reduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1006 Power seating system, combination tilt and recline, without shear reduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1007Power seating system, combination tilt and recline, with mechanical sheerreduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1008Power seating system, combination tilt and recline, with power shearreduction HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1009Addition to power seating system, mechanically linked leg elevation system,including pushrod and leg rest, each HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1010Addition to power seating system, power leg elevation system, including legrest, pair HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1011Modification to pediatric size wheelchair, width adjustment package (not tobe dispensed with initial chair) HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE1014 Reclining back, addition to pediatric size wheelchair HCPC Letter of medical Necessity supporting need for the wheelchair accessoryHistory and Physical to Include the following: diagnosis; abilities and limitations asE1031 Rollabout chair, any and all types with casters five inches or greater HCPCthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asE1035Multi positional patient transfer system, with integrated seat, operated bycaregiverHCPCthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthE1036Multi‐positional patient transfer system, extra‐wide, with integrated seat,operated by caregiver, patient weight capacity greater than 300 lbsHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 31 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperE1037 Transport chair, pediatric size HCPC extremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalTransport chair, adult size, patient weight capacity up to an including 300condition, Past experience if any using similar equipment, Evaluation of upperE1038 poundsHCPC extremity strengthE1039E1050E1060E1070E1083Transport chair, adult size, heavy duty, patient weight capacity greater than300 pounds HCPCFully‐reclining wheelchair, fixed full‐length arms, swing‐away detachableelevating legrestsFully‐reclining wheelchair, detachable arms, desk or full‐length, swing‐awaydetachable elevating legrestsFully‐reclining wheelchair, detachable arms (desk or full‐length) swing‐awaydetachable footrestHemi‐wheelchair; fixed full‐length arms, swing‐away, detachable, elevatinglegrestsHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 32 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1084Hemi‐wheelchair, detachable arms desk or full‐length arms, swing‐awaydetachable elevating legrestsHCPCE1085 Hemi‐wheelchair, fixed full‐length arms, swing‐away detachable footrests HCPCE1086E1087E1088E1089E1090Hemi‐wheelchair, detachable arms, desk or full‐length, swing‐awaydetachable footrestsHigh strength lightweight wheelchair, fixed full‐length arms, swing‐awaydetachable elevating legrestsHigh strength lightweight wheelchair, detachable arms desk or full‐length,swing‐away detachable elevating legrestsHigh‐strength lightweight wheelchair, fixed‐length arms, swing‐awaydetachable footrestHigh‐strength lightweight wheelchair, detachable arms, desk or full‐length,swing‐away detachable footrestsHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 33 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1092E1093E1100E1110E1130E1140E1150Wide heavy‐duty wheel chair, detachable arms (desk or full‐length), swingawaydetachable elevating legrestsWide heavy‐duty wheelchair, detachable arms, desk or full‐length arms,swing‐away detachable footrestsSemi‐reclining wheelchair, fixed full‐length arms, swing‐away detachableelevating legrestsSemi‐reclining wheelchair, detachable arms (desk or full‐length) elevatinglegrestStandard wheelchair; fixed full‐length arms, fixed or swing‐away, detachablefootrestsWheelchair, detachable arms, desk or full‐length; swing‐away, detachablefootrestsWheelchair, detachable arms, desk or full‐length swing‐away detachableelevating legrestsHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 34 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1160Wheelchair, fixed full‐length arms, swing‐away, detachable, elevatinglegrestsHCPCE1161 Manual adult size wheelchair, includes tilt in space HCPCE1170Amputee wheelchair; fixed full‐length arms, swing‐away, detachable,elevating legrestsHCPCE1171 Amputee wheelchair, fixed full‐length arms, without footrests or legrest HCPCE1172E1180E1190Amputee wheelchair, detachable arms (desk or full‐length) without footrestsor legrestAmputee wheelchair, detachable arms (desk or full‐length) swing‐awaydetachable footrestsAmputee wheelchair, detachable arms (desk or full‐length) swing‐awaydetachable elevating legrestsHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 35 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1195E1200E1220Heavy duty wheelchair; fixed full‐length arms, swing‐away, detachable,elevating legrestsAmputee wheelchair; fixed full‐length arms, swing‐away, detachablefootrestsWheelchair; specially sized or constructed, (indicate brand name, modelnumber, if any) and justificationHCPCHCPCHCPCE1221 Wheelchair with fixed arm, footrests HCPCE1222 Wheelchair with fixed arm, elevating legrests HCPCE1223 Wheelchair with detachable arms, footrests HCPCE1224 Wheelchair with detachable arms, elevating legrests HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 36 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1225Wheelchair accessory, manual semi‐reclining back, (recline greater than 15degrees, but less than 80 degrees), eachHCPCE1226 Wheelchair accessory, manual, fully reclining back (recline >80°), each HCPCE1229 Wheelchair, pediatric size, not otherwise specified HCPCE1230Power operated vehicle (three‐ or four‐wheel nonhighway), specify brandname and model numberHCPCE1231 Wheelchair, pediatric size, tilt‐in‐space, rigid, adjustable, with seating system HCPCE1232Wheelchair; Pediatric size, tilt‐in‐space, folding, adjustable, with seatingsystemHCPCE1233 Pediatric size, tilt‐in‐space, rigid, adjustable, without seating system HCPCE1234 Pediatric size, tilt‐in‐space, folding adjustable with seating system HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength, Documented inability to propel a manual chairHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 37 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.E1235 Pediatric size, folding, adjustable, with seating system HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.E1236 Wheelchair, pediatric size, folding, adjustable, with seating system HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.E1237 Pediatric size, rigid, adjustable, without seating system HCPCE1238 Pediatric size, folding, adjustable, without seating system HCPCE1240E1250E1260Lightweight wheelchair, detachable arms, (desk or full‐length) swing‐awaydetachable, elevating legrestLightweight wheelchair, fixed full‐length arms, swing‐away detachablefootrestLightweight wheelchair, detachable arms (desk or full‐length) swing‐awaydetachable footrestHCPCHCPCHCPCLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performed.Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 38 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1270E1280E1285E1290Lightweight wheelchair, fixed full‐length arms, swing‐away detachableelevating legrestsHeavy duty wheelchair; detachable arms, desk or full‐length, elevatinglegrestsHeavy‐duty wheelchair, fixed full‐length arms, swing‐away detachablefootrestHeavy‐duty wheelchair, detachable arms (desk or full‐length) swing‐awaydetachable footrestHCPCHCPCHCPCHCPCE1295 Heavy‐duty wheelchair, fixed full‐length arms, elevating legrest HCPCE1800E1801E1802E1805Dynamic adjustable elbow extension/flexion device, includes soft interfacematerialStatic progressive stretch elbow device, extension and/or flexion, with orwithout range of motion adjustment, includes all components andaccessoriesDynamic adjustable forearm pronation/supination device, includes softinterface materialDynamic adjustable wrist extension/flexion device, includes soft interfacematerialHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.Letter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 39 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1806E1810E1811Static progressive stretch wrist device, flexion and/or extension, with orwithout range of motion adjustment, includes all components andaccessoriesDynamic adjustable knee extension/flexion device, includes soft interfacematerialStatic progressive stretch knee device, extension and/or flexion, with orwithout range of motion adjustment, includes all components andaccessoriesHCPCHCPCHCPCE1812 Dynamic knee, extension/flexion device with active resistance control HCPCE1815E1816E1818E1820E1821E1825Dynamic adjustable ankle extension/flexion device, includes soft interfacematerialStatic progressive stretch ankle device, flexion and/or extension, with orwithout range of motion adjustment, includes all components andaccessoriesStatic progressive stretch forearm pronation/supination device, with orwithout range of motion adjustment, includes all components andaccessoriesReplacement soft interface material, dynamic adjustable extension/flexiondeviceReplacement soft interface material/cuffs for bi‐directional static progressivestretch deviceDynamic adjustable finger extension/flexion device, includes soft interfacematerialHCPCHCPCHCPCHCPCHCPCHCPCLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 40 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestE1830E1831E1840Dynamic adjustable toe extension/flexion device, includes soft interfacematerialStatic progressive stretch toe device, extension and/or flexion, with orwithout range of motion adjustment, includes all components andaccessoriesDynamic adjustable shoulder flexion/abduction/rotation device, includessoft interface materialStatic progressive stretch shoulder device, with or without range of motionadjustment, includes all components and accessoriesHCPCHCPCHCPCLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedLetter of medical necessity containing the following information: Anticipated lengthof time patient will require the equipment, Description of medical conditionrequiring use of this equipment including mobility status, Surgical proceduredescription and Date if any performedE1841HCPCLetter of medical Necessity supporting need for the wheelchair accessory. IncludeE2227 Manual wheelchair accessory, gear reduction drive wheel, each HCPC invoice of cost for item.Manual wheelchair accessory, wheel braking system and lock, complete,Letter of medical Necessity supporting need for the wheelchair accessory. IncludeE2228 eachHCPC invoice of cost for item.E2230 Manual wheelchair accessory, manual standing system HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2293Back, contoured, for pediatric size wheelchair including fixed attachinghardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2294Seat, contoured, for pediatric size wheelchair including fixed attachinghardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2295Manual wheelchair accessory, for pediatric size wheelchair, dynamic seatingframe, allows coordinated movement of multiple positioning features HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2310Power wheelchair accessory, electronic connection between wheelchaircontroller and one power seating system motor, including all relatedelectronics, indicator feature, mechanical function selection switch, andfixed mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2311Electronic connection between wheelchair controller and two or more powerseating system motors, including all related electronics, indicator HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2331Power wheelchair accessory, attendant control, proportional, including allrelated electronics and fixed mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2341 Power wheelchair accessory, nonstandard seat frame width, 24‐27 in HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2342 Non‐standard seat frame depth, 20 or 21 inches HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2343 Power wheelchair accessory, nonstandard seat frame depth, 22‐25 in HCPC Letter of medical Necessity supporting need for the wheelchair accessoryCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 41 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestPower wheelchair accessory, electronic interface to operate speechE2351 generating device using power wheelchair control interface HCPC Letter of medical Necessity supporting need for the wheelchair accessorySpeech generating device, digitized speech, using pre‐recorded messages,Letter of Medical Necessity including length of time equipment needed,functionalE2500 less than or equal to eight minutes recording timeHCPC status if applicable and description of medical conditionE2502Speech generating device, digitized speech, using prerecorded messages,greater than 8 minutes but less than or equal to 20 minutes recording timeHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2504Speech generating device, digitized speech, using prerecorded messages,greater than 20 minutes but less than or equal to 40 minutes recording time HCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2506Speech generating device, digitized speech, using prerecorded messages,greater than 40 minutes recording timeHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2508Speech generating device, synthesized speech, requiring messageformulation by spelling and access by physical contact with the device HCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2510Speech generating device, synthesized speech, permitting multiple methodsof message formulation and multiple methods of device accessHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2511Speech generating software program, for personal computer or personaldigital assistantHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2512 Accessory for speech generating device, mounting system HCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionE2603 Skin protection wheelchair seat cushion, width less than 22 in., any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2604 Width 22 in. or greater, any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2605 Positioning wheelchair seat cushion, width less than 22 in., any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2606 Width 22 in. or greater, any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2607Skin protection and positioning wheelchair seat cushion, width less than 22in., any depthHCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2608 Width 22 in. or greater, any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2609 Custom fabricated wheelchair seat cushion, any size HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2610 Wheelchair seat cushion, powered HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2613Positioning wheelchair back cushion, posterior, width less than 22 in., anyheight, including any type mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2614 Width 22 in. or greater, any height, including any type mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryPosterior‐lateral, width less than 22 in., any height, including any typeE2615 mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2616 Width 22 in. or greater, any height, including any type mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 42 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestCustom fabricated wheelchair back cushion, any size, includes any typeE2617 mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryPositioning wheelchair back cushion, planar back with lateral supports, widthE2620 less than 22 in., any height, including any type mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2621 Width 22 in. or greater, any height, including any type mounting hardware HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2622Skin protection wheelchair seat cushion, adjustable, width less than 22 in,any depth HCPC Letter of medical Necessity supporting need for the wheelchair accessoryE2623Skin protection wheelchair seat cushion, adjustable, width 22 in or greater,any depthHCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2624Skin protection and positioning wheelchair seat cushion, adjustable, widthless than 22 in, any depthHCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.E2625Skin protection and positioning wheelchair seat cushion, adjustable, width22 in or greater, any depth HCPCLetter of medical Necessity supporting need for the wheelchair accessory. Includeinvoice of cost for item.G0341Percutaneous islet cell transplant, includes portal vein catheterization andinfusionHCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantG0342Laparoscopy for islet cell transplant, includes portal vein catheterization andinfusionHCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantG0343Laparotomy for islet cell transplant, includes portal vein catheterization andinfusionHCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantG0448Insertion or replacement of a permanent pacing cardioverter‐defibrillatorsystem with transvenous lead(s), single or dual chamber with insertion ofpacing electrode, cardiac venous system, for left ventricular pacing HCPC History and Physical, documentation of medical necessity and procedure reportJ0129 Injection, abatacept, 10 mg HCPCHistory and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedJ0215 Injection, alefacept, 0.5 mg HCPCHistory and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedJ0490 Injection, belimumab, 10 mg HCPC History and physical, documentation of medical necessity, treatment planJ0717Injection, certolizumab pegol, 1 mg (code may be used for Medicare whendrug administered under the direct supervision of a physician, not for usewhen drug is self administered)HCPCHistory and Physical, clinical notes related to a condition being treated,documentation of previous therapies tried and failed.J0718 Injection, certolizumab pegol, 1 mg HCPCHistory and Physical, Office notes related to a condition being treated,documentation of previous therapies tried and failed.J0881 Injection, darbepoetin alfa, 1 mcg (non‐ESRD use) HCPCSubmit chart notes from the ordering physician including history and physical withHgb level and transferrin saturation or ferritin level within 1 month of initiating ESAand monthly. Allow under age 18.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 43 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestSubmit chart notes from the ordering physician including history and physical withHgb level and transferrin saturation or ferritin level within 1 month of initiating ESAJ0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) HCPC and monthly. Allow under age 18.Submit chart notes from the ordering physician including history and physical withHgb level and transferrin saturation or ferritin level within 1 month of initiating ESAJ0885 Injection, epoetin alfa, (for non‐ESRD use), 1000 units HCPC and monthly. Allow under age 18.Submit chart notes from the ordering physician including history and physical withHgb level and transferrin saturation or ferritin level within 1 month of initiating ESAJ0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) HCPC and monthly. Allow under age 18.History and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedJ1325 Injection, epoprostenol, 0.5 mg HCPCInjection, immune globulin (Privigen), intravenous, nonlyophilized (e.g.,J1459 liquid), 500 mg HCPC History and Physical and recent lab workInjection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g.,J1557 liquid), 500 mg HCPC History and Physical and recent lab workJ1559 Injection, immune globulin (Hizentra), 100 mg HCPC History and Physical and recent lab workJ1561Injection, immune globulin, (Gamunex), intravenous, nonlyophilized (e.g.,liquid), 500 mg HCPC History and Physical and recent lab workJ1562 Injection, immune globulin (Vivaglobin), 100 mg HCPC History and Physical and recent lab workJ1566Injection, immune globulin, intravenous, lyophilized (e.g., powder), nototherwise specified, 500 mg HCPC History and Physical and recent lab workJ1568Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g.,liquid), 500 mg HCPC History and Physical and recent lab workJ1569Injection, immune globulin, (Gammagard liquid), intravenous,nonlyophilized, (e.g., liquid), 500 mg HCPC History and Physical and recent lab workJ1572Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous,nonlyophilized (e.g., liquid), 500 mg HCPC History and Physical and recent lab workJ1599Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), nototherwise specified, 500 mg HCPC History and Physical and recent lab workJ1602 Injection, golimumab, 1 mg, for intravenous use HCPCHistory and Physical, clinical notes related to a condition being treated,documentation of previous therapies tried and failed.History and physical including prior treatments and results. Do not send infusionJ1745 Injection infliximab, 10 mg HCPC records!J2170 Injection, mecasermin, 1 mg HCPC History and Physical, including prior treatments and proposed treatment planJ2357 Injection, omalizumab, 5 mg HCPCJ3262 Injection, tocilizumab, 1 mg (Actemra) HCPCHistory and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedHistory and physical demonstrating reason for requested medication, dosage andduration of treatment, office notes related to conditionCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 44 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestJ3285 Injection, treprostinil, 1 mg HCPCHistory and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedJ3357 Injection, ustekinumab, 1 mg HCPC History and Physical, clinical notes from ordering provider, treatment planJ9035 Injection, bevacizumab, 10 mg HCPCHistory and Physical including prior treatments and proposed treatment plan.Please do not send infusion records. Allow if billed with diagnosis code 362.52.J9055 Injection, cetuximab, 10 mg HCPC History and Physical, including prior treatments and proposed treatment planJ9213 Injection, interferon, alfa‐2a, recombinant, 3 million units HCPCJ9214 Injection, interferon, alfa‐2b, recombinant, 1 million units HCPCPHARMACY: Fax BA to Pharmacy review @ 888‐260‐9836. Submit office notesrelated to condition, medical necessity and documentation of previoustherapies/treatments tried,dosage and duration of treatment. Review Pegasys only.PHARMACY: Fax BA to Pharmacy review @ 888‐260‐9836. Submit office notesrelated to condition, medical necessity and documentation of previoustherapies/treatments tried,dosage and duration of treatment. Review Peg‐Intrononly.J9300 Injection, gemtuzumab ozogamicin, 5 mg HCPCHistory and physical demonstrating reason for requested medication, lab work ifapplicable, dosage and duration of treatment, office notes related to condition,medical necessity and documentation of previous therapies/treatments triedJ9303 Injection, panitumumab, 10 mg HCPC History and Physical, including prior treatments and proposed treatment planJ9310 Injection, rituximab, 100 mg HCPCHistory and physical demonstrating reason for requested medication, dosage andduration of treatment, office notes related to condition. Do not send infusionrecords!J9355 Injection, trastuzumab, 10 mg HCPCHistory and physical demonstrating reason for requested medication, and lab workdemonstrating HER‐2/neu over expression. Do not send infusion records!History and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength. Include invoice of cost for item.K0003K0004Lightweight wheelchairHigh strength, lightweight wheelchairHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asK0005 Ultralight weight wheelchair HCPCthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 45 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition). Past experience if any using similar equipment,K0008 Custom manual wheelchair base HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperK0009 Other manual wheelchair/base HCPC extremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperK0010 Standard – weight frame motorized/power wheelchair HCPC extremity strength, Documented inability to propel a manual chairHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength, Documented inability to propel a manual chairK0011Standard‐weight frame motorized/power wheelchair with programmablecontrol parameters for speed adjustment, tremor dampening, accelerationcontrol and brakingHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength, Documented inability to propel a manual chairK0012 Lightweight portable motorized/power wheelchair HCPCHistory and Physical, Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition). Past experience if any using similar equipment.K0013 Custom motorized/power wheelchair base HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strength, Documented inability to propel a manual chairK0014 Other motorized/power wheelchair base HCPCK0108 Wheelchair component or accessory, not otherwise specified HCPC Letter of medical Necessity supporting need for the wheelchair accessoryAutomatic external defibrillator, with integrated electrocardiogram analysis,K0606 garment type HCPC Recent History and Physical, plan of care, and documentation of medical necessityCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 46 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestWheelchair accessory, wheelchair seat or back cushion, does not meetK0669 specific code criteria or no written coding verification from SADMERC HCPC Letter of medical Necessity supporting need for the wheelchair accessoryHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthK0800K0801K0802K0806K0807K0808Power operated vehicle, group 1 standard, patient weight capacity up to andincluding 300 poundsHCPCPower operated vehicle, group 1 heavy‐duty, patient weight capacity 301 to450 pounds HCPCPower operated vehicle, group 1 very heavy‐duty, patient weight capacity451 to 600 pounds HCPCPower operated vehicle, group 2 standard, patient weight capacity up to andincluding 300 poundsHCPCPower operated vehicle, group 2 heavy‐duty, patient weight capacity 301 to450 pounds HCPCPower operated vehicle, group 2 very heavy‐duty, patient weight capacity451 to 600 pounds HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 47 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthK0812 Power operated vehicle, not otherwise classified HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthK0813K0814K0815K0816K0820K0821Power wheelchair, group 1 standard, portable, sling/solid seat and back,patient weight capacity up to and including 300 poundsPower wheelchair, group 1 standard, portable, captain's chair, patientweight capacity up to and including 300 poundsPower wheelchair, group 1 standard, sling/solid seat and back, patientweight capacity up to and including 300 poundsPower wheelchair, group 1 standard, captain's chair, patient weight capacityup to and including 300 poundsPower wheelchair, group 2 standard, portable, sling/solid seat/back, patientweight capacity up to and including 300 poundsPower wheelchair, group 2 standard, portable, captain's chair, patientweight capacity up to and including 300 poundsHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 48 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0822K0823K0824K0825K0826K0827K0828Power wheelchair, group 2 standard, sling/solid seat/back, patient weightcapacity up to and including 300 poundsPower wheelchair, group 2 standard, captain's chair, patient weight capacityup to and including 300 poundsPower wheelchair, group 2 heavy‐duty, sling/solid seat/back, patient weightcapacity 301 to 450 poundsPower wheelchair, group 2 heavy‐duty, captain's chair, patient weightcapacity 301 to 450 poundsPower wheelchair, group 2 very heavy duty, sling/solid seat/back, patientweight capacity 451 to 600 poundsPower wheelchair, group 2 very heavy‐duty, captain's chair, patient weightcapacity 451 to 600 poundsPower wheelchair, group 2 extra heavy‐duty, sling/solid seat/back, patientweight capacity 601 pounds or moreHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 49 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0829K0830K0831K0835K0836K0837K0838Power wheelchair, group 2 extra heavy‐duty, captain's chair, patient weight601 pounds or more HCPCPower wheelchair, group 2 standard, seat elevator, sling/solid seat/back,patient weight capacity up to and including 300 poundsPower wheelchair, group 2 standard, seat elevator, captain's chair, patientweight capacity up to and including 300 poundsPower wheelchair, group 2 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 2 standard, single power option, captain's chair,patient weight capacity up to and including 300 poundsPower wheelchair, group 2 heavy‐duty, single power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 2 heavy‐duty, single power option, captain's chair,patient weight capacity 301 to 450 poundsHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 50 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0839K0840K0841K0842K0843K0849K0850Power wheelchair, group 2 very heavy‐duty, single power option sling/solidseat/back, patient weight capacity 451 to 600 poundsPower wheelchair, group 2 extra heavy‐duty, single power option, sling/solidseat/back, patient weight capacity 601 pounds or morePower wheelchair, group 2 standard, multiple power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 2 standard, multiple power option, captain's chair,patient weight capacity up to and including 300 poundsPower wheelchair, group 2 heavy‐duty, multiple power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 3 standard, captain's chair, patient weight capacityup to and including 300 poundsPower wheelchair, group 3 heavy‐duty, sling/solid seat/back, patient weightcapacity 301 to 450 poundsHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 51 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0851K0852K0853K0854K0855K0856K0857Power wheelchair, group 3 heavy‐duty, captain's chair, patient weightcapacity 301 to 450 poundsPower wheelchair, group 3 very heavy‐duty, sling/solid seat/back, patientweight capacity 451 to 600 poundsPower wheelchair, group 3 very heavy‐duty, captain's chair, patient weightcapacity 451 to 600 poundsPower wheelchair, group 3 extra heavy‐duty, sling/solid seat/back, patientweight capacity 601 pounds or morePower wheelchair, group 3 extra heavy duty, captain's chair, patient weightcapacity 601 pounds or morePower wheelchair, group 3 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 3 standard, single power option, captain's chair,patient weight capacity up to and including 300 poundsHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 52 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0858K0859K0860K0861K0862K0863K0864Power wheelchair, group 3 heavy‐duty, single power option, sling/solidseat/back, patient weight 301 to 450 poundsPower wheelchair, group 3 heavy‐duty, single power option, captain's chair,patient weight capacity 301 to 450 poundsPower wheelchair, group 3 very heavy‐duty, single power option, sling/solidseat/back, patient weight capacity 451 to 600 poundsPower wheelchair, group 3 standard, multiple power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 3 heavy‐duty, multiple power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 3 very heavy‐duty, multiple power option,sling/solid seat/back, patient weight capacity 451 to 600 poundsPower wheelchair, group 3 extra heavy‐duty, multiple power option,sling/solid seat/back, patient weight capacity 601 pounds or moreHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 53 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0868K0869K0870K0871K0877K0879K0880Power wheelchair, group 4 standard, sling/solid seat/back, patient weightcapacity up to and including 300 poundsPower wheelchair, group 4 standard, captain's chair, patient weight capacityup to and including 300 poundsPower wheelchair, group 4 heavy‐duty, sling/solid seat/back, patient weightcapacity 301 to 450 poundsPower wheelchair, group 4 very heavy‐duty, sling/solid seat/back, patientweight capacity 451 to 600 poundsPower wheelchair, group 4 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 4 heavy‐duty, single power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 4 very heavy‐duty, single power option, sling/solidseat/back, patient weight 451 to 600 poundsHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 54 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestK0884K0885K0886K0890K0891Power wheelchair, group 4 standard, multiple power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 4 standard, multiple power option, captain's chair,patient weight capacity up to and including 300 poundsPower wheelchair, group 4 heavy‐duty, multiple power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 5 pediatric, single power option, sling/solidseat/back, patient weight capacity up to and including 125 poundsPower wheelchair, group 5 pediatric, multiple power option, sling/solidseat/back, patient weight capacity up to and including 125 poundsHCPCHCPCHCPCHCPCHCPCK0898 Power wheelchair, not otherwise classified HCPCK0900 Customized durable medical equipment, other than wheelchair HCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical, Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition). Past experience if any using similar equipment.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 55 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestKnee orthotic, double upright, thigh and calf, with adjustable flexion andextension joint (unicentric or polycentric), medial‐lateral and rotationL1846 control, with or without varus/valgus adjustment, custom fabricatedHCPCL5856L5857L5858L5973L6025L6715Addition to lower extremity prosthesis, endoskeletal knee‐shin system,microprocessor control feature, swing and stance phase, includes electronicsensor(s), any typeAddition to lower extremity prosthesis, endoskeletal knee‐shin system,microprocessor control feature, swing phase only, includes electronicsensor(s), any typeAddition to lower extremity prosthesis, endoskeletal knee shin system,microprocessor control feature, stance phase only, includes electronicsensor(s), any typeEndoskeletal ankle foot system, microprocessor controlled feature,dorsiflexion and/or plantar flexion control, includes power sourceTranscarpal/metacarpal or partial hand disarticulation prosthesis, externalpower, self‐suspended, inner socket with removable forearm section,electrodes and cables, 2 batteries, charger, myoelectric control of terminaldeviceHCPCHCPCHCPCHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical condition. No review is needed forFEP.Letter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionHistory and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.HCPCTerminal device, multiple articulating digit, includes motor(s), initial issue orreplacement HCPC History and Physical, physiatrist documentation of physical capacityL6880L6925L6935L6945Electric hand, switch or myolelectric controlled, independently articulatingdigits, any grasp pattern or combination of grasp patterns, includes motor(s) HCPC History and Physical, physiatrist documentation of physical capacityWrist disarticulation, external power, self‐suspended inner socket,removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteriesHistory and physical, letter of medical necessity and functional status eval fromand one charger, myoelectronic control of terminal deviceHCPC physiatrist or physical therapist.Below elbow, external power, self‐suspended inner socket, removableforearm shell, Otto Bock or equal electrodes, cables, 2 batteries and onecharger, myoelectronic control of terminal deviceElbow disarticulation, external power, molded inner socket, removablehumeral shell, outside locking hinges, forearm, Otto Bock or equalelectrodes, cables, 2 batteries and one charger, myoelectronic control ofterminal deviceHCPCHCPCHistory and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.L6955L6975Above elbow, external power, molded inner socket, removable humeralshell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables,2 batteries and one charger, myoelectronic control of terminal device HCPCInterscapular‐thoracic, external power, molded inner socket, removableshoulder shell, shoulder bulkhead, humeral section, mechanical elbow,forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger,myoelectronic control of terminal devHCPCL7007 Electric hand, switch or myoelectric controlled, adult HCPCHistory and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromphysiatrist or physical therapist.CPT codes, descriptions and material are copyrighted by the American Medical Association. Page 56 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestHistory and physical, letter of medical necessity and functional status eval fromL7008 Electric hand, switch or myoelectric, controlled, pediatric HCPC physiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromL7009 Electric hook, switch or myoelectric controlled, adult HCPC physiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromL7045 Electric hook, switch or myoelectric controlled, pediatric HCPC physiatrist or physical therapist.Electronic elbow, adolescent, Variety Village or equal, myoelectronicallyHistory and physical, letter of medical necessity and functional status eval fromL7190 controlledHCPC physiatrist or physical therapist.History and physical, letter of medical necessity and functional status eval fromL7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled HCPC physiatrist or physical therapist.L8680 Implantable neurostimulator electrode, each HCPC Recent History and Physical, plan of care, and documentation of medical necessityL8681Patient programmer (external) for use with implantable programmableneurostimulator pulse generatorHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8682 Implantable neurostimulator radiofrequency receiver HCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8683Radiofrequency transmitter (external) for use with implantableneurostimulator radiofrequency receiverHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8684Radiofrequency transmitter (external) for use with implantable sacral rootneurostimulator receiver for bowel and bladder management, replacement HCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8685Implantable neurostimulator pulse generator, single array, rechargeable,includes extensionHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8686Implantable neurostimulator pulse generator, single array, nonrechargeable,includes extensionHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8687Implantable neurostimulator pulse generator, dual array, rechargeable,includes extensionHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8688Implantable neurostimulator pulse generator, dual array, nonrechargeable,includes extensionHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8689External recharging system for battery (internal) for use with implantableneurostimulatorHCPCLetter of Medical Necessity including length of time equipment needed,functionalstatus if applicable and description of medical conditionL8691 Auditory osseointegrated device, external sound processor, replacement HCPCPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentL8693 Auditory osseointegrated device abutment, any length, replacement only HCPCPre Operative Evaluation, Operative Report, Previous use of hearing aids, Level ofhearing ImpairmentL8695External recharging system for battery (external) for use with implantableneurostimulator, replacement onlyHCPCPeer Reviewed Literature supporting requested procedure, Recent History andPhysicalP9020 Platelet rich plasma, each unit HCPC History and Physical, plan of care description of wound location, depth, sizeQ2043Sipuleucel‐t, minimum of 50 million autologous cd54+ cells activated withpap‐gm‐csf, including leukapheresis and all other preparatory procedures,per infusionHCPCHistory and physical, clinical notes related to a condition being treated, treatmentplanS0088 Imatinib, 100 mg HCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 57 of 58 027236 (10‐2014)

Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestS2080 Laser‐assisted uvulopalatoplasty (LAUP) HCPC History and Physical, including Sleep study results, results of CPAP trialIf transplant approval on record: Date of Transplant If no Transplant approval:S2102 Islet cell tissue transplant from pancreas; allogeneic HCPC History and Physical, Transplant evaluation, and date of transplantS2103 Adrenal tissue transplant to brain HCPC Recent History and Physical, plan of care, and documentation of medical necessityS2140 Cord blood harvesting for transplantation, allogeneic HCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantS2142 Cord blood‐derived stem‐cell transplantation, allogeneic HCPCIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantS2230Implantation of magnetic component of semi‐implantavle hearing device onossicles in middle ear HCPC History and Physical, Operative reportS2360Percutaneous vertebroplasty, one vertebral body, unilateral or bilateralinjection; cervical HCPC Pre Operative Evaluation, History and Physical, and Operative reportS2361Each additional cervical vertebral body (list separately in addition to code forprimary procedure) HCPC Pre Operative Evaluation, History and Physical, and Operative reportS8130 Interferential current stimulator, 2 channel HCPC History and Physical, plan of careS8131 Interferential current stimulator, 4 channel HCPC History and Physical, plan of careS9055 Procuren or other growth factor preparation to promote wound healing HCPC History and Physical, including previous conservative treatments and surgeries triedS9960Ambulance service, conventional air services, nonemergency transport, oneway (fixed wing)HCPCSubmit progress notes for last 24 hours prior to transport, physician order includingmedical records supporting rationale for transportS9961Ambulance service, conventional air service, nonemergency transport, oneway (rotary wing)HCPCSubmit progress notes for last 24 hours prior to transport, physician order includingmedical records supporting rationale for transportV5095 Semi‐implantable middle ear hearing prosthesis HCPC History and Physical, Operative reportCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 58 of 58 027236 (10‐2014)