Prior authorization means that your doctor must get approval from Blue Shield before prescribing specific medications or performing a particular medical service or operation. Without this prior approval, Blue Shield may not pay for your medication or medical procedure, and you will have to pay out of pocket.
To see if a particular service or drug requires prior authorization, you can search the prior authorization list below. Just enter the procedure or drug name in the “Search for Procedures” field. If your entry is on the list, then you will need to work with your doctor to get prior authorization before Blue Shield will pay.
Remember, it’s always important to check that the service or drug you need is a covered benefit under your plan. For any questions 关于 prior authorization, please call Customer Service at the number on the back of your Blue Shield member ID card.
足球外围官网平台
| MEDICAL POLICY | PROCEDURE CODES |
|---|---|
| Actigraphy | 95803 |
| Adalimumab (Humira®) Abbott Pharmaceutical | J0135 |
| Administrative-Medical - ABA Therapy | 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, 0374T, 90899, 96151, 96152, 96153, 96154, 96155, 99499, G8539, G9012, H0031, H0032, H2012, H2014, H2019, S5108, S5110, S5111 |
| Administrative-Medical - ASC Steerage | 19340, 23410, 23412, 23420, 23605, 23615, 23630, 24505, 24515, 24516, 24535, 24538, 24545, 24546, 24575, 24579, 24586, 24620, 24635, 24655, 24685, 25505, 25515, 25520, 25525, 25526, 25545, 25565, 25574, 25575, 25605, 25628, 25645, 25652, 27310, 27331, 27332, 27333, 27334, 27335, 27403, 27405, 27407, 27535, 27536, 27650, 27652, 27654, 27685, 27686, 27752, 27756, 27758, 27759, 27766, 27784, 27792, 27814, 27822, 27823, 27826, 27827, 27828, 27848, 28415, 28420, 28445, 38700, 42410, 42415, 42420, 43280, 44970, 47564, 51990, 51992, 53230, 53235, 53265, 53400, 53405, 53410, 53415, 53420, 53430, 53450, 53460, 53502, 53505, 53520, 58700, 58740, 59150, 59151, 60200, 60210, 60212, 60225, 62350, 62351, 62361, 62362, 67036, 67039, 67040, 67101, 67110 |
| Administrative-Medical - Acute Detox (Residential Addiction Program Inpatient) | H0011 |
| Administrative-Medical - Acute Detox (Residential Addiction Program Outpatient) | H0013 |
| Administrative-Medical - Acute Detox Inpatient | H0009 |
| Administrative-Medical - Air Ambulance | A0430 |
| Administrative-Medical - Ambulatory Detox | H0014 |
| Administrative-Medical - Behavioral Health | 90870, S9480 |
| Administrative-Medical - Bone Marrow Transplant | 38204, 38205, 38206, 38207, 38230, 38240, 38241, 38242, 86813, 86817 |
| Administrative-Medical - Continuous Home Hospice | T2043 |
| Administrative-Medical - Dialysis | 90935, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90993, 90999 |
| Administrative-Medical - Factor for the Treatment of Hemophilia | J7175, J7183, J7185, J7186, J7187, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7196, J7197, J7198, J7199, J7201, J7205, J7207 |
| Administrative-Medical - Heart Lung Transplant | 33935 |
| Administrative-Medical - Heart Transplant | 33945 |
| Administrative-Medical - Hemodialysis | 90937 |
| Administrative-Medical - Home Hospice | Q5010, S9126, T2042 |
| Administrative-Medical - Home Infusion | S9379 |
| Administrative-Medical - Hospice Care (Assisted Living Facility) | Q5002 |
| Administrative-Medical - Hospice Care (Hospice Inpatient Facility) | Q5006 |
| Administrative-Medical - Hospice Care (Inpatient Hospital) | Q5005 |
| Administrative-Medical - Hospice Care (Inpatient Psych Facility) | Q5008 |
| Administrative-Medical - Hospice Care (Long-Term Care Facility) | Q5007 |
| Administrative-Medical - Hospice Care (Skilled Nursing Facility) | Q5004 |
| Administrative-Medical - Inpatient Injectable/Infusion | 96413, 96415, 96416, 96417, 96440, 96446, 96450, 96542, 96549 |
| Administrative-Medical - Intensive Outpatient Services Substance Abuse | H0015, H2034 |
| Administrative-Medical - Intestine/Bowel Transplant | 44135, 44136 |
| Administrative-Medical - Liver Transplant | 47135 |
| Administrative-Medical - Lung Transplant | 32852, 32854 |
| Administrative-Medical - Nursing/Shift Care | S9123, S9124 |
| Administrative-Medical - Outpatient Program | 19301, 19303, 19304, 20670, 20680, 23130, 23415, 23625, 24360, 24361, 24362, 24363, 24370, 24371, 24565, 24577, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25447, 25535, 25606, 25607, 25608, 25609, 26992, 27176, 27178, 27250, 27252, 27265, 27266, 27330, 27409, 27457, 27530, 27532, 27550, 27552, 27556, 27557, 27558, 27606, 27705, 27769, 27780, 27781, 27840, 27842, 27846, 28292, 28296, 28297, 28298, 28299, 29826, 29827, 29830, 29834, 29835, 29836, 29837, 29838, 29840, 29843, 29844, 29845, 29846, 29847, 29855, 29856, 29860, 29861, 29862, 29863, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29882, 29883, 29884, 29885, 29886, 29887, 29891, 29892, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 32601, 32606, 32607, 32608, 32609, 32650, 32651, 32652, 32653, 32655, 32656, 32664, 32666, 32667, 32668, 33270, 33820, 33822, 33824, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37241, 37242, 37244, 38720, 38724, 39401, 39402, 41135, 42425, 42426, 43499, 44180, 44950, 45560, 49321, 49322, 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 50080, 50081, 50432, 50693, 50694, 50695, 51020, 51040, 51045, 51050, 51060, 51065, 51520, 51525, 51530, 51535, 51840, 51841, 51845, 51980, 52214, 52224, 52234, 52235, 52240, 52250, 52334, 52450, 52630, 52647, 52648, 52649, 53425, 53431, 53510, 53515, 53850, 53852, 54300, 54304, 54308, 54312, 54316, 54318, 54322, 54324, 54326, 54328, 54332, 54336, 54340, 54344, 54348, 54352, 54380, 54385, 54390, 54520, 54522, 54530, 54535, 54690, 57240, 57270, 57289, 57425, 58660, 58662, 58670, 58671, 58672, 58673, 58679, 58720, 58760, 58770, 58805, 58822, 58900, 58920, 58925, 58940, 59120, 59121, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60500, 60502, 60650, 61791, 63600, 64600, 64605, 64610, 65091, 65093, 65101, 65103, 65105, 67041, 67042, 67043, 67105, 67107, 67108, 67113, 92920, 92921, 92924, 92925, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92986, 92987, 92990, 93640, 93641, 93655 |
| Administrative-Medical - Pancreas Transplant | 48554 |
| Administrative-Medical - Partial Hospitalization | H0035 |
| Administrative-Medical - Peritoneal Dialysis | 90945 |
| Administrative-Medical - Solid Organ Transplant | Q0508, S9975 |
| Administrative-Medical - Subacute Detox (Residential Addiction Program Outpatient) | H0012 |
| Administrative-Medical - Subacute Detox Inpatient | H0008 |
| Administrative-Medical - Subacute Detox Inpatient (Residential Addiction Program Inpatient) | H0010 |
| Administrative-Medical - Therapeutic Behavioral Services | H2020 |
| Administrative-Pharmacy | S9560 |
| Ado-Trastuzumab Emtansine (Kadcyla®) | J9354 |
| Aflibercept (Eylea®) Regeneron Pharmaceuticals | J0178 |
| Agalsidase Beta (Fabrazyme®) | J0180 |
| Aldesleukin (Proleukin, IL-2, Interleukin) | J9015 |
| Alemtuzumab Inj (LEMTRADA®) | J0202 |
| Alglucosidase Alfa (Lumizyme®) Genzyme Corp | J0221 |
| Anidulafungin (Eraxis) | J0348 |
| Apomorphine (Apokyn®) Mylan, Inc | J0364 |
| Aripiprazole Injection (Abilify Maintena) | J0401 |
| Aripiprazole Lauroxil Injection (Aristada®) | J1942 |
| Asparaginase Erwinia Chrysanthemi (Erwinaze) EUSA Pharma | J9019 |
| Atezolizumab (Tecentriq) | J9022 |
| Auditory Brainstem Implant | S2235 |
| Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions | 27412, J7330, S2112 |
| Avelumab (Bavencio) | J9023 |
| Azacitidine (Vidaza) | J9025 |
| Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis | 31295, 31296, 31297, 31298 |
| Bariatric Surgery | 43632, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43886, 43887, 43888, 43999 |
| Belatacept (Nulojix) | J0485 |
| Belimumab (Benlysta®) GlaxoSmithKline | J0490 |
| Belinostat (Beleodaq™) | J9032 |
| Bendamustine (Bendeka) | J9034 |
| Bendamustine (Treanda®) | J9033 |
| Benralizumab (Fasenra) | J0517 |
| Beta-Amyloid Imaging With Positron Emission Tomography for Alzheimer Disease | 78811, 78814 |
| Bevacizumab (Avastin®) Genentech | J9035 |
| Bezlotoxumab (Zinplava) | J0565 |
| Biofeedback as a Treatment of Urinary Incontinence in Adults | 90901, 90911, E0746 |
| Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure | 33208, 33224 |
| Blepharoplasty, Blepharoptosis Repair, (Levator Resection) and Brow Lift (Repair of Brow Ptosis) | 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909 |
| Blinotumomab (Blincyto®) | J9039 |
| Bortezomib (Velcade®) Millenium | J9041 |
| Botulinum Toxin A AbobotulinumtoxinA (Dysport®) | J0586 |
| Botulinum Toxin A IncobotulinumtoxinA (Xeomin®) | J0588 |
| Botulinum Toxin B RimabotulinumtoxinB (Myobloc®) | J0587 |
| Botulinum Toxin Type A OnobotulinumtoxinA (Botox®) | J0585 |
| Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | 77316, 77317, 77318, 77778 |
| Breast Implant Management | 19328, 19330, 19340, 19342, 19370, 19371, C1789, L8030, L8039, L8600 |
| Brentuximab Vedotin (Adcetris™) | J9042 |
| Buprenorphine Implant (Probuphine) | J0570 |
| Buprenorphine extended-release injection (Sublocade) | Q9991, Q9992 |
| Burosumab-twza (Crysvita) | J0584 |
| C1 Esterase Inhibitor (Berinert®; CLS Behring, Cinryze®; Lev Pharmaceuticals) | J0597, J0598 |
| C1 Esterase Inhibitor Recombinant (RUCONEST) | J0596 |
| C1 Esterase inhibitor (Haegarda) | J0599 |
| Cabazitaxel (Jevtana®) | J9043 |
| Canakinumab (Ilaris®) Novartis | J0638 |
| Capsaicin 8% Patch (Qutenza®) NeurogesX, Inc | J7336 |
| Cardiac Applications of Positron Emission Tomography Scanning | 78459, 78491, 78492 |
| Carfilzomib (Kyprolis®) | J9047 |
| Caspofungin (Cancidas®) Merck | J0637 |
| Catheter Ablation for Cardiac Arrhythmias | 93650, 93653, 93654 |
| Cerliponase Alfa (Brineura) | J0567 |
| Certolizumab Pegol (Cimzia) | J0717 |
| Cetuximab (Erbitux®) Bristol-Myers Squibb | J9055 |
| Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions | 77520, 77522, 77523, 77525 |
| Clinical Trials | S9988, S9990, S9991, S9992, S9994, S9996 |
| Clofarabine (Clolar®) Genzyme, Inc. | J9027 |
| Cochlear Implant | 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, L8629 |
| Collagenase Clostridium Histolyticum (Xiaflex®) Auxilium Pharmaceuticals | J0775 |
| Computed Tomography Perfusion Imaging of the Brain | 0042T |
| Computed Tomography to Detect Coronary Artery Calcification | 75571 |
| Computer-Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast | 0159T |
| Continuous Passive Motion in the Home Setting | E0935, E0936 |
| Copanlisib (Aliqopa) | J9057 |
| Corticotropin, Repository (H.P. Acthar® Gel) Questcor | J0800 |
| Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors | 19105, 20983, 32994, 50250, 50542, 50593 |
| Dalbavancin (Dalvance™) | J0875 |
| Dalteparin (Fragmin) | J1645 |
| Daratumumab (Darzalex) | J9145 |
| Darbepoetin Alfa (Aranesp®) Amgen | J0881 |
| Daunorubicin Cytarabine Liposome (Vyxeos) | J9153 |
| Decitabine (Dacogen) | J0894 |
| Degarelix (Firmagon®) Ferring Pharmaceuticals | J9155 |
| Denosumab (Prolia™) Amgen | J0897 |
| Denosumab (Xgeva) | J0897 |
| Dental Anesthesia | 00170 |
| Dexamethasone Intravitreal Implant (Ozurdex®) | J7312 |
| Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome | 95782, 95783, 95800, 95801, 95805, 95807, 95808, 95810, 95811, E0485, E0486, E0601, G0400 |
| Dihydroergotamine Mesylate Injection (D.H.E. 45®) | J1110 |
| Durvalumab (Imfinzi) | J9173 |
| Durvalumab (Imfinzi) | C9492 |
| Ecallantide (Kalbitor®) Dyax | J1290 |
| Eculizumab (Soliris®) Alexion | J1300 |
| Edaravone (Radicava) | J1301 |
| Elective Percutaneous Coronary Intervention (PCI) | 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, C1874, C9600, C9601, C9602, C9603, C9604, C9605, C9607, C9608 |
| Elosulfase Alfa (Vimizim®) | J1322 |
| Elotuzumab (Empliciti®) | J9176 |
| Endobronchial Brachytherapy | 31643, 77316, 77317, 77318, 77761, 77762, 77763, 77770, 77771, 77772 |
| Enoxaparin (Lovenox) | J1650 |
| Epoetin Alfa (Procrit®) Ortho Biotech | J0885 |
| Epoetin Alfa-epbx (Retacrit) | Q5106 |
| Epoprostenol (Flolan®) Gilead or generic manufacturers (Veletri®) Actelion Pharmaceuticals | J1325 |
| Eribulin (Halaven) | J9179 |
| Etanercept (Enbrel®) Amgen, Inc. | J1438 |
| Eteplirsen (Exondys 51) | J1428 |
| External Insulin Infusion Pump | E0784 |
| Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions | 0101T, 0102T, 28890 |
| Filgrastim, G-CSF, (Neupogen®) | J1442 |
| Filgrastim-Sndz (Zarxio®) | Q5101 |
| Filgrastim-aafi (Nivestym) | Q5110 |
| Fluocinolone Intravitreal Implant (Iluvein®) | J7313 |
| Fluocinolone Intravitreal Implant (Retisert®) | J7311 |
| Fondaparinux (Arixtra®) GlaxoSmithKline | J1652 |
| Fulvestrant (Faslodex®) AstraZeneca | J9395 |
| Functional Neuromuscular Electrical Stimulation | E0744, E0764, E0770 |
| Galsulfase (Naglazyme®) Biomarine | J1458 |
| Gemtuzumab Ozogamicin (Mylotarg) | J9203 |
| Gender Reassignment Surgery | 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 11971, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17380, 19301, 19303, 19304, 19325, 19340, 19342, 19357, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 31750, 53410, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55150, 55175, 55180, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 57530, 58150, 58180, 58260, 58262, 58263, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58555, 58570, 58571, 58572, 58573, 58661, 58720, 58940, 92507, 92508, C1813, C2622 |
| Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers | 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81479 |
| Genetic Testing for Inherited Thrombophilia | 81240, 81241, 81291 |
| Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes | 81201, 81202, 81203, 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81403, 81406 |
| Genetic Testing for Mitochondrial Disorders | 81460, 81465 |
| Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy | 81406, 81479 |
| Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer | 81479, 81599 |
| Golimumab (Simponi Aria®) | J1602 |
| Granisetron (Sustol) | J1627 |
| Growth Hormone (GH) in Adults and Children,Somatropin Products:(Humatrope®), Eli Lilly (Nutropin®/NutropinAQ®), Genentech (Genotropin®), Pharmacia/Pfizer (Norditropin®), NovoNordisk (Saizen®), Serono (Tev-Tropin®), Teva (Omnitrope®), Sandoz | J2941 |
| Guselkumab (Tremfya) | J1628 |
| High-Dose Rate Temporary Prostate Brachytherapy | 77316, 77317, 77318, 77770, 77771, 77772, 77778 |
| Histrelin Implant (Supprelin LA®) Indevus | J9226 |
| Histrelin Implant (Vantas™) Indevus | J9225 |
| Hyaluronic Acid (Euflexxa® Ferring) | J7323 |
| Hyaluronic Acid (Gel One®/ Seikagaku) | J7326 |
| Hyaluronic Acid (GelSyn-3®) | J7328 |
| Hyaluronic Acid (GenVisc®) | J7320 |
| Hyaluronic Acid (Hyalgan® Fidia/Sanofi Supartz® Seikagaku /Smith and Nephew) | J7321 |
| Hyaluronic Acid (Hymovis) | J7322 |
| Hyaluronic Acid (Monovisc®) | J7327 |
| Hyaluronic Acid (Orthovisc®) | J7324 |
| Hyaluronic Acid (Synvisc®, Synvisc One®) | J7325 |
| Hyaluronic Acid (Trivisc) | J7329 |
| Hydroxyprogesterone Caproate (Medicare Makena) | J1726 |
| Hydroxyprogesterone Caproate, not otherwise specified (generic for Makena) | J1729 |
| Hyperbaric Oxygen Therapy | 99183, A4575, E0446, G0277 |
| Hysterectomy Surgery for Benign Conditions | 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59525 |
| IV Antibiotics for Tickborne Infections | J0456, J0558, J0561, J0696, J0698, J1956, J2540 |
| Ibalizumab-uiyk (Trogarzo) | J1746 |
| Ibandronate (Boniva®) Roche | J1740 |
| Ibritumomab (Zevalin) | A9542, A9543 |
| Icatibant (Firazyr®) | J1744 |
| Idursulfase (Elaprase®) Shire | J1743 |
| Iloprost inhalation (Ventavis®) | Q4074 |
| Imiglucerase (Cerezyme®) Genzyme | J1786 |
| Immune Globulin, Intravenous IVIG | 90291, J0850, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599 |
| Immune Globulin, Subcutaneous (Hizentra® 20%) CSL Behring | J1559, J1575 |
| Implantable Bone-Conduction and Bone-Anchored Hearing Aids | 69710, 69711, 69714, 69715, 69717, 69718, L8690, L8691, L8693 |
| Implantable Cardioverter Defibrillator | 33216, 33217, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 93287, C1721, C1722, C1777, C1882, C1895, C1896, G0448 |
| Implantation of Intrastromal Corneal Ring Segments | 65785 |
| Infliximab (Remicade®), Centocor | J1745 |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | 51715, L8603, L8606 |
| Inotuzumab Ozogamicin (Besponsa) | J9229 |
| Intensity-Modulated Radiotherapy of the Breast and Lung | 77385, 77386, G6015, G6016 |
| Intensity-Modulated Radiotherapy of the Prostate | 77385, 77386, G6015, G6016 |
| Intensity-Modulated Radiotherapy: Abdomen and Pelvis | 77385, 77386, G6015, G6016 |
| Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid | 77385, 77386, G6015, G6016 |
| Intensity-Modulated Radiotherapy: Central Nervous System Tumors | 77385, 77386, G6015, G6016 |
| Interferon Alfa 2b (Intron A®) Schering | J9214 |
| Interferon Alfa-n3 (Alferon N®) Purdue | J9215 |
| Interferon Gamma-1b (Actimmune®) InterMune | J9216 |
| Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment | 78811, 78812, 78813, 78814, 78815, 78816 |
| Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain | 77761, 77762, 77763, 77770, 77771, 77772 |
| Iobenguane I-131 (Azedra) | C9407, C9408 |
| Ipilimumab (Yervoy) Bristol-Myers Squibb | J9228 |
| Irinotecan Liposome Injection (Onivyde®) | J9205 |
| Isavuconazonium (Cresemba®) | J1833 |
| Ixabepilone (Ixempra®) Bristol-Myers Squibb | J9207 |
| KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer | 81210 |
| Knee Arthroplasty for Adults | 27447 |
| Knee Arthroscopy in Knee Osteoarthritis | 29880, 29881 |
| Knee Braces | L1840, L1844, L1846 |
| Lanreotide (Somatuline®) Ipsen Pharma Biotech | J1930 |
| Laronidase (Aldurazyme®) BioMarin Pharmaceutical | J1931 |
| Levoleucovorin Inj (Fusilev®) Spectrum Pharmaceuticals | J0641 |
| Linezolid (Zyvox®) Pharmacia and Upjohn/Pfizer | J2020 |
| Lower Limb Prostheses | L5100, L5105, L5150, L5160, L5200, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5617, L5700, L5701, L5702, L5930, L5990 |
| Lutetium Lu 177 Dotatate (Lutathera) | A9513 |
| Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer | 77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908 |
| Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants | 77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908 |
| Magnetic Resonance Spectroscopy | J76390 |
| Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders | 95012 |
| Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk | 83698 |
| Mecasermin (Increlex®) Tercica | J2170 |
| Melphalan (Evomela) | J9245 |
| Mepolizumab (Nucala®) | J2182 |
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®) | J0888 |
| Methylnaltrexone (Relistor®) | J2212 |
| Micafungin (Mycamine®) Astellas Pharma | J2248 |
| Microprocessor-Controlled Prostheses for the Lower Limb | L5856, L5857, L5858, L5859, L5973 |
| Microwave and Locoregional Laser Tumor Ablation | 47370, 47380, 47382 |
| Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816 |
| Moderate Penetrance Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk | 81406 |
| Mogamulizumab-kpkc (Poteligeo) | C9038 |
| Multigene Expression Assay for Predicting Recurrence in Colon Cancer | 84999 |
| Multiple Sclerosis Drug Therapy | J1830 |
| Multiple Sclerosis Drug Therapy Glatiramer (Copaxone®, Glatopa) | J1595 |
| Multiple Sclerosis Drug Therapy Interferon beta 1A (Avonex®), Biogen | J1826 |
| NIA Pain/Spine | 0095T, 0098T, 0163T, 0164T, 0165T, 0195T, 0196T, 0200T, 0201T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T, 0274T, 0275T, 22526, 22527, 22533, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899, 27096, 62263, 62264, 62287, 62320, 62321, 62322, 62323, 62380, 63001, 63005, 63012, 63015, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63047, 63050, 63051, 63056, 63057, 63075, 63076, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, G0260, M0076, S2348, S2350, S2351 |
| NIA Radiology | 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 75635, 76380, 77011, 77012, 77013, 77021, 77022, 77084, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 78499, G0297, S8037, S8092 |
| Natalizumab (Tysabri®) Biogen Idec | J2323 |
| Necitumumab (Portrazza) | J9295 |
| Negative Pressure Wound Therapy in the Outpatient Setting | 97605, 97606, A6550, A9272, E2402, K0743, K0744, K0745, K0746 |
| Neuropsychological Testing | 96116, 96132, 96133 |
| Nivolumab (Opdivo®) | J9299 |
| Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA | 81420, 81479, 81599, 84999 |
| Nonpharmacologic Treatment of Rosacea | 30117 |
| Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease | 82172, 82610, 82664, 83695, 83700, 83701, 83704, 85384, 85385 |
| Nusinersen (Spinraza) | J2326 |
| Obinutuzumab (Gazyva®) | J9301 |
| Ocrelizumab (Ocrevus) | J2350 |
| Ocriplasmin (Jetrea®) | J7316 |
| Octreotide (Sandostatin® SC/IV) Novartis | J2354 |
| Octreotide IM Injection (Sandostatin LAR Depot®) Novartis | J2353 |
| Ofatumumab (Arzerra®) GlaxoSmithKline | J9302 |
| Olanzapine Long-Acting Injection (Zyprexa® Relprevv™) Eli Lilly | J2358 |
| Olaratumab (Lartruvo) | J9285 |
| Omacetaxine (Synribo) | J9262 |
| Omalizumab (Xolair®) Genentech | J2357 |
| Oncologic Applications of Positron Emission Tomography Scanning | 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0235, G0252, S8085 |
| Oritavancin (Orbactiv™) | J2407 |
| Orthognathic Surgery | 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21247, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996 |
| Orthopedic Applications of Platelet-Rich Plasma | 0232T |
| Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow) | 38206, 38230, 38241 |
| Orthoptic Training for the Treatment of Vision or Learning Disabilities | 92065 |
| Paclitaxel Protein Bound Suspension (Abraxane®) Abraxis Oncology | J9264 |
| Palifermin (Kepivance®) | Amgen |
| Paliperidone (Invega Sustenna®) Janssen | J2426 |
| Palivizumab (Synagis®) MedImmune | 90378 |
| Palonosetron (Aloxi®) Distributed by Eisai Inc. Licensed by Helsinn | J2469 |
| Panitumumab (Vectibix®) | J9303 |
| Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti | 15830, 15847 |
| Partial Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression | 29826, 29827 |
| Pasireotide Diaspartate (Signifor®, Signifor LAR®) | J2502 |
| Patisiran (Onpattro) | C9036 |
| Pegaptanib (Macugen®) Pfizer | J2503 |
| Pegfilgrastim (Neulasta®) | J2505 |
| Pegfilgrastim-cbqv (Udenyca) | Q5111 |
| Pegfilgrastim-jmdb (Fulphila) | Q5108 |
| Pegloticase (Krystexxa) Savient Pharmaceuticals | J2507 |
| Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | E0740 |
| Pembrolizumab (Keytruda®) | J9271 |
| Pemetrexed (Alimta), Eli Lilly | J9305 |
| Peramivir (Rapivab™) | J2547 |
| Percutaneous Tibial Nerve Stimulation | 64566 |
| Pertuzumab (Perjeta®) | J9306 |
| Plerixafor (Mozobil®) | J2562 |
| Positron Emission Mammography | 78811, G0235 |
| Power Wheelchairs and Power Operated Vehicles for Permanent Use | E1016, E1018, E2300, E2301, E2310, E2311, E2351, E2358, E2360, E2362, E2364, E2367, E2372, E2609, E2610, E2617, K0669, K0806, K0807, K0808, K0830, K0831, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886 |
| Pralatrexate (Folotyn) | J9307 |
| Protein C Concentrate (human) (Ceprotin®) | J2724 |
| Radioembolization for Primary and Metastatic Tumors of the Liver | 37243, 75894, 77399, 77778, 79445, C2616, S2095 |
| Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | 20982, 32998, 50542, 50592, 76940 |
| Radium Ra 223 Dichloride (Xofigo) | A9606 |
| Ramucirumab (Cyramza®) | J9308 |
| Ranibizumab (Lucentis®) | J2778 |
| Reconstructive Services | 11950, 11951, 11952, 11954, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17380, 19325, 19350, 19355, 19357, 19370, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 31750, 57335, 92507, 92508 |
| Reduction Mammaplasty for Breast-Related Symptoms | 19318 |
| Reslizumab (Cinqair) | J2786 |
| Rilonacept (Arcalyst®) | J2793 |
| Risperidone Long-acting Injection (Risperdal Consta®) | J2794 |
| Risperidone extended-release (Perseris) | C9037 |
| Rituxan Hyaluronidase (Rituxan Hycela) | J9311 |
| Rituximab (Rituxan) | J9312 |
| Rituximab (Rituxan®), Genentech | J9310 |
| Rolapitant (Varubi) | C9464 |
| Romidepsin (Istodax®) | J9315 |
| Romiplostim (Nplate™) | J2796 |
| Sargramostim, GM-CSF (Leukine®) | J2820 |
| Sebelipase (Kanuma®) | J2840 |
| Semi-Implantable and Fully Implantable Middle Ear Hearing Aids | S2230, V5095 |
| Siltuximab (Sylvant™) | J2860 |
| Sodium Hyaluronate (Durolane) | J7318 |
| Subcutaneous Immune Globulin (Cuvitru) | J1555 |
| Subtalar Arthroereisis | 28725, 28735 |
| Sumatriptan Injection (Imitrex®, Sumavel™, Dosepro™) | J3030 |
| Surgical Deactivation of Headache Trigger Sites | 15824, 15826, 30130, 30140, 30520, 64716, 67900 |
| Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea | 64999 |
| Surgical Treatment of Bilateral Gynecomastia | 19300, 19301, 19303, 19304 |
| Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome | 21685, 41512, 41530, 42145, 42299 |
| Taliglucerase alfa (Elelyso®) | J3060 |
| Talimogene Laherparepvec (Imlygic) | J9325 |
| Tbo-Filgrastim (Granix®) | J1447 |
| Tedizolid (Sivextro™) | J3090 |
| Temsirolimus (Torisel®) | J9330 |
| Teriparatide (Forteo®) | J3110 |
| Testosterone undecanoate (Aveed®) | J3145 |
| Tildrakizumab-asmn (Ilumya) | J3245 |
| Tisagenlecleucel (Kymriah) | Q2042 |
| Tocilizumab (Actemra®) | J3262 |
| Total Artificial Hearts and Implantable Ventricular Assist Devices | 33927, 33928, 33929 |
| Total Hip Arthroplasty for Adults | 27130 |
| Trabectedin (Yondelis®) | J9352 |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | 90867, 90868, 90869 |
| Trastuzumab (Herceptin®) | J9355 |
| Treatment of Varicose Veins/Venous Insufficiency | 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37765, 37766, S2202 |
| Treprostinil IV (Remodulin®) | J3285 |
| Treprostinil inhalation (Tyvaso®) | J7686 |
| Triptorelin (Triptodur) | J3316 |
| Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis | 0126T |
| Unlisted-Pharmacy | J3490, J3590, J7699, J7799, J8499, J8999, J9999 |
| Ustekinumab Subcutaneous (Stelara) | J3357 |
| Ustekinumab intravenous (Stelara) | J3358 |
| Vedolizumab (Entyvio®) | J3380 |
| Velaglucerase alfa (VPRIV™) | J3385 |
| Vestronidase Alfa-vjbk (Mepsevii) | J3397 |
| Vincristine liposome (Marqibo®) | J9371 |
| Virtual Colonoscopy/Computed Tomography Colonography | 74261, 74262, 74263 |
| Voretigene Neparvovec-rzyl (Luxturna) | J3398 |
| Wearable Cardioverter Defibrillators | 93292, 93745, K0606, K0607, K0608, K0609 |
| Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders | 81415, 81416 |
| Whole Gland Cryoablation of Prostate Cancer | 55873 |
| Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon | 91110, 91111 |
| Ziconotide (Prialt®) | J2278 |
| ZivAflibercept (Zaltrap®) | J9400 |