| Procedure |
Policy Number |
Title |
|
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
220.13 |
Percutaneous Image Guided Breast Biopsy |
|
8XXXX
|
20.9.1 |
Ventricular Assist Devices |
|
8XXXX
|
20.9.1 |
Ventricular Assist Devices |
|
8XXXX
|
20.9.1 |
Ventricular Assist Devices |
|
8XXXX
|
20.9.1 |
Ventricular Assist Devices |
|
8XXXX
|
20.7 |
Percutaneous Transluminal Angioplasty (PTA) |
|
8XXXX
|
260.1 |
Adult Liver Transplantation |
|
8XXXX
|
260.1 |
Adult Liver Transplantation |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
80.11 |
Vitrectomy |
|
8XXXX
|
210.14 |
Lung Cancer Screening with Low Dose Computed Tomography (LDCT) |
|
8XXXX
|
150.3 |
Bone Mineral Density |
|
8XXXX
|
220.4 |
Mammograms |
|
8XXXX
|
220.4 |
Mammograms |
|
8XXXX
|
220.4 |
Mammograms |
|
8XXXX
|
220.4 |
Mammograms |
|
8XXXX
|
150.3 |
Bone Mineral Density |
|
8XXXX
|
150.3 |
Bone Mineral Density |
|
8XXXX
|
150.3 |
Bone Mineral Density |
|
8XXXX
|
150.3 |
Bone Mineral Density |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
220.6.17 |
FDG PET for Head and Neck Cancers |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.33 |
Hepatitis Panel/Acute Hepatitis Panel |
|
8XXXX
|
190.24 |
Digoxin Therapeutic Drug Assay |
|
8XXXX
|
90.2 |
Next Generation Sequencing (NGS) |
|
8XXXX
|
210.3 |
Multitarget Stool DNA (sDNA) Colorectal Cancer Screening Test - Cologuard |
|
8XXXX
|
190.25 |
Alpha-fetoprotein |
|
8XXXX
|
190.34 |
Fecal Occult Blood Test |
|
8XXXX
|
190.26 |
Carcinoembryonic Antigen |
|
8XXXX
|
190.5 |
Sweat Test |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.19 |
Collagen Crosslinks, Any Method |
|
8XXXX
|
190.18 |
Serum Iron Studies |
|
8XXXX
|
190.20 |
Blood Glucose Testing |
|
8XXXX
|
190.20 |
Blood Glucose Testing |
|
8XXXX
|
190.20 |
Blood Glucose Testing |
|
8XXXX
|
190.32 |
Gamma Glutamyl Transferase |
|
8XXXX
|
190.21 |
Glycated Hemoglobin/Glycated Protein |
|
8XXXX
|
190.21 |
Glycated Hemoglobin/Glycated Protein |
|
8XXXX
|
190.18 |
Serum Iron Studies |
|
8XXXX
|
190.18 |
Serum Iron Studies |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.31 |
Prostate Specific Antigen |
|
8XXXX
|
190.22 |
Thyroid Testing |
|
8XXXX
|
190.22 |
Thyroid Testing |
|
8XXXX
|
190.22 |
Thyroid Testing |
|
8XXXX
|
190.18 |
Serum Iron Studies |
|
8XXXX
|
190.23 |
Lipids Testing |
|
8XXXX
|
190.22 |
Thyroid Testing |
|
8XXXX
|
190.27 |
Human Chorionic Gonadotropin |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.15 |
Complete Blood Count |
|
8XXXX
|
190.17 |
Prothrombin Time (PT) |
|
8XXXX
|
190.16 |
Partial Thromboplastin Time (PTT) |
|
8XXXX
|
190.29 |
Tumor Antigen by Immunoassay CA 15-3/CA 27.29 |
|
8XXXX
|
190.30 |
Tumor Antigen by Immunoassay CA 19-9 |
|
8XXXX
|
190.28 |
Tumor Antigen by Immunoassay CA 125 |
|
8XXXX
|
190.8 |
Lymphocyte Mitogen Response Assays |
|
8XXXX
|
190.8 |
Lymphocyte Mitogen Response Assays |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.1 |
Histocompatibility Testing |
|
8XXXX
|
190.12 |
Urine Culture, Bacterial |
|
8XXXX
|
190.12 |
Urine Culture, Bacterial |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.13 |
Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.14 |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
|
8XXXX
|
190.13 |
Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.3 |
Cytogenetic Studies |
|
8XXXX
|
190.5 |
Sweat Test |
|
8XXXX
|
20.30 |
Microvolt T-Wave Alternans (MTWA) |
|
8XXXX
|
20.16 |
Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) |
|
8XXXX
|
270.6 |
Infrared Therapy Devices |
|
8XXXX
|
180.1 |
MNT Services |
|
8XXXX
|
180.1 |
MNT Services |
|
8XXXX
|
180.1 |
MNT Services |
|
8XXXX
|
20.29 |
Hyperbaric Oxygen Therapy |
|
8XXXX
|
210.4.1 |
Counseling to Prevent Tobacco Use |
|
8XXXX
|
210.4.1 |
Counseling to Prevent Tobacco Use |
|
G0102
|
210.1 |
Prostate Cancer Screening Tests |
|
G0103
|
210.1 |
Prostate Cancer Screening Tests |
|
G0105
|
210.3 |
Colorectal Cancer Screening Tests |
|
G0108
|
40.1 |
Diabetes Outpatient Self-Management Training |
|
G0109
|
40.1 |
Diabetes Outpatient Self-Management Training |
|
G0120
|
210.3 |
|
|
G0123
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0124
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0130
|
150.3 |
Bone Mineral Density |
|
G0141
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0143
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0144
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0145
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0147
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0148
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
G0202
|
220.4 |
Mammograms |
|
G0204
|
220.4 |
Mammograms |
|
G0206
|
220.4 |
Mammograms |
|
G0248
|
190.11 |
Home Prothrombin Time INR Monitoring for Anticoagulation Management |
|
G0249
|
190.11 |
Home Prothrombin Time INR Monitoring for Anticoagulation Management |
|
G0250
|
190.11 |
Home Prothrombin Time INR Monitoring for Anticoagulation Management |
|
G0270
|
180.1 |
MNT Services |
|
G0271
|
180.1 |
MNT Services |
|
G0277
|
20.29 |
Hyperbaric Oxygen Therapy |
|
G0279
|
220.4 |
Mammograms |
|
G0281
|
270.1 |
Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds |
|
G0296
|
210.14 |
Lung Cancer Screening with Low Dose Computed Tomography (LDCT) |
|
G0327
|
210.3 |
|
|
G0329
|
270.1 |
Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds |
|
G0432
|
210.7 |
HIV Screening |
|
G0433
|
210.7 |
HIV Screening |
|
G0435
|
210.7 |
HIV Screening |
|
G0460
|
270.3 |
Blood Derived Products for Chronic Non-healing Wounds |
|
G0464
|
210.3 |
Multitarget Stool DNA (sDNA) Colorectal Cancer Screening Test - Cologuard |
|
G0472
|
210.13 |
Screening for Hepatitis C Virus in Adults |
|
G0475
|
210.7 |
HIV Screening |
|
G0476
|
210.2.1 |
HPV screening |
|
G0499
|
210.6 |
Screening for Hepatitis B Virus (HBV) Infection |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
8XXXX
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
P3000
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
P3001
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
Q0091
|
210.2 |
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer |
|
Q0162
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
Q0166
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
Q0180
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
|
Q0181
|
110.18 |
Aprepitant for Chemotherapy-Induced Emesis |
