Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

Code

Description

11200 - effective 1/1/17 11201 - effective 1/1/17 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15820

15847 15876 15877 15878 17360

Removal of skin tags, multiple fibrocutaneous tags any area up and including 15 lesions - effective 1/1/17 Skin tag removal, each additional 10 lesions, effective 1/1/17 Dermabrasion; Total Face Dermabrasion; Segmental, Face Dermabrasion; Regional, Other Than Face Dermabrasion; Superficial, Any Site Abrasion; Single Lesion Abrasion; Add'l 4 Lesions/< Chemical Peel, Facial; Epidermal Chemical Peel, Facial; Dermal Chemical Peel, Nonfacial; Epidermal Chemical Peel, Nonfacial; Dermal Blepharoplasty, Lower Eyelid Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad Rhytidectomy; Forehead Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap) Rhytidectomy; Glabellar Frown Lines Rhytidectomy; Cheek, Chin, & Neck Rhytidectomy; Superficial Musculoaponeurotic System (Smas) Flap Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy), Abdomen Suction assisted lipectomy Suction assisted lipectomy suction assisted lipectomy Chemical Exfoliation, Acne

19105 19300

Ablation, Cryosurgical, of Fibroadenoma, including Ultrasound Guidance, Each Fibroadenoma Gynecomastia surgery

15821 15824 15825 15826 15828 15829

Updated 1/1/2017

Clinical Edit Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic Always Cosmetic

Always Investigational Always Cosmetic

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

20983

Ablation therapy for reduction or eradication of 1 or more bone tumors (eg. Metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation

22526

Computer-Assisted Surgical Navigational Procedure for Musculoskeletal Procedures; Image-Less (List Sep) Percutaneous Intradiscal Electrothermal Annuloplasty, Unilateral or Bilateral including Fluoroscopic Guidance; Sgl Level

22527

Percutaneous Intradiscal Electrothermal Annuloplasty, Unilateral or Bilateral; One or More Additional Levels

20985

27279

28890

31295 31296 31297

31647 31648 31649

Updated 1/1/2017

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Always Investigational Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, plantar fascia Always Investigational Nasal/Sinus Endoscopy, Surgical; With Dilation Of Maxillary Sinus Ostium, Transnasal Or Via Canine Fossa Nasal/Sinus Endoscopy, Surgical; With Dilation Of Frontal Sinus Ostium (Eg, Balloon Dilation) Nasal/Sinus Endoscopy, Surgical; With Dilation Of Sphenoid Sinus Ostium (Eg, Balloon Dilation) Bronchoscopy; W Balloon Occlusn, Assessmt Of Air Leak, Airway Sizing, And Insertion Of Bronchial Valve(s), Initial Lobe Bronchoscopy; With Removal Of Bronchial Valve(s), Initial Lobe Bronchoscopy; With Removal Of Bronchial Valve(s), Each Additional Lobe

Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

31651 31660 31661

33270 33271 33273 43206 43252

43257

43647 43648 43881 43882

Updated 1/1/2017

Bronchoscopy; W Balloon Occlusn, Assessmt Of Air Leak, Airway Sizing, And Insertion Of Bronchial Valve(s), Ea Addl Lobe Always Investigational Bronchoscopy; With Bronchial Thermoplasty, 1 Lobe Always Investigational Bronchoscopy; With Bronchial Thermoplasty, 2 Or More Lobes Always Investigational Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Insertion of subcutaneous implantable defibrillator electrode Repositioning of previously implanted subcutaneous implantable defibrillator electrode Esophagoscopy, Rigid Or Flexible; With Optical Endomicroscopy Upper Gastrointestinal Endoscopy; With Optical Endomicroscopy Ugi Endoscopy; With Delivery Of Thermal Energy To The Muscle Of Lower Esophageal Sphincter And/Or Gastric Cardia Laparoscopy, Surgical; Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum Laparoscopy, Surgical; Revision or Removal of Gastric Neurostimulator Electrodes, Antrum Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum, Open Revision or Removal of Gastric Neurostimulator Electrodes, Antrum, Open

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

64595 64999 75571 77061 77062

Aspiration/Decompression, Percutaneous, Nucleus Pulposus, Any Meth, Single/Multiple Levels, Lumbar Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar Incision & Subq Placement, Peripheral Neurostimulator Pulse Generator/Receiver Revision/Removal, Peripheral Neurostimulator Pulse Generator/Receiver Unlisted Proc, Nervous System CT heart cardiac structure and morphology Digital breast tomosynthesis; unilateral Digital breast tomosynthesis; bilateral

77063 80184 80299

Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) Assay Of Phenobarbital Quantitation, Drug, Not Elsewhere Specified

62287

62292 64590

81291

Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19), Gene Analysis, Common Variants Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6), Gene Analysis, Common Variants Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9), Gene Analysis, Common Variants (Eg, *2, *3, *5, *6) Mthfr (5,10-Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common Variants

81313

PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer)

81225 81226

81227

Updated 1/1/2017

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

81332

81350

81355 81410

81411 81415

81416

81417

81425

81426

Updated 1/1/2017

SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z) Always Investigational Ugt1A1 (Udp Glucuronosyltransferase 1 Family, Polypeptide A1) (Eg, Irinotecan Metabolism), Gene Analysis,Common Variants Always Investigational Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common Variants Always Investigational Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK Always Investigational Duplication/deletion analysis panel, must include Always Investigational analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Always Investigational sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for Always Investigational primary procedure) re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated Always Investigational condition/syndrome) Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Always Investigational Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure) Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 81427

Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome) Always Investigational

81430

81431

81435

81436

81440

Updated 1/1/2017

Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1 Always Investigational duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 Always Investigational and GJB6 genes Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and Always Investigational PMS2 duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH Always Investigational Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

81455 81460

81465

81470

81471

Updated 1/1/2017

Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection

Always Investigational

Always Investigational Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy Always Investigational detection, if performed X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 Always Investigational duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 81490

Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score Always Investigational

81493

Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score Always Investigational

81500

Oncology (Ovarian), Biochemical Assays Of Two Proteins, Serum, W Menopausal Status, Algorithm Reported As A Risk Score Always Investigational

81525

Oncology (Ovarian), Biochemical Assays Of Five Proteins, Utilizing Serum, Algorithm Reported As A Risk Score Oncology Tissue of Origin Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffinembedded tissue, algorithm reported as a recurrence score

81528 - No longer investigational as of 1/1/17 82163 82172 82726 82777 83695

Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Code will be covered as of 1/1/17 - no longer investigational) Angiotensin II Apolipoprotein, Each Very Long Chain Fatty Acids Galectin-3 Lipoprotein (a)

81503 81504

81519

Updated 1/1/2017

Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 83698 83700 83701

83704 83718 83719 83992 83993 86001

86152

86153 86332 86910 86911 86999

90644 90739 92065

Updated 1/1/2017

Lipoprotein-Associated Phospholipase A2, (Lp-Pla2) Lipoprotein, blood; electrophoretic separation and quantitation Lipoprotein, blood; high resolution fractionation and quantitation, w/wo lipoprotein subclasses Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses Lipoprotein, Direct Measurement; High Density Cholesterol (Hdl Cholesterol) Lipoprotein, Direct Measurement; Direct Measurement, Vldl Cholesterol Phencyclidine (Pcp) Calprotectin, Fecal Allergen specific IgG quantitative or semiquantitative, each allergen Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); interpretation and report Immune Complex Assay Blood typing, for paternity testing, per individual; ABO, Rh and MN Blood typing, for paternity testing, per individual; each additional antigen system Unlisted Transfusion Medicine Proc Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenC Hepatitis B Vaccine, Adult Dosage (2 Dose Schedule), For Intramuscular Use Orthoptic &/Or Pleoptic Training, W/Continuing Medical Direction & Evaluation

Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational Always Non-covered Always Non-covered Always Investigational

Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

92520

Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report Nasal function studies (eg, rhinomanometry) Laryngeal function studies (ie, aerodynamic testing and acoustic testing)

93050

Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, noninvasive

93260

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system Always Investigational

93261

Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system Always Investigational

92145 92512

96931

96932

96933

Updated 1/1/2017

Always Investigational Always Investigational Always Investigational

Always Investigational

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion Always Investigational Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion Always Investigational Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

96934

96935

96936 93702 93740 93760 93762 93895

95980

95981

95982 97012 0019T

0054T

Updated 1/1/2017

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure) Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure) Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure) Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) Thermal imaging Thermogram, Cephalic Thermography Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral Electronic Analysis of Implanted Gastric Neurostimulator Pulse Generator/Transmitter; Intraoperative, with Programming Electronic Analysis of Implanted Gastric Neurostimulator Pulse Generator/Transmitter; Subsequent, Without Reprogramming Electronic Analysis of Implanted Gastric Neurostimulator Pulse Generator/Transmitter; Subsequent, with Reprogramming Application of a modality to 1 or more areas; traction, mechanical Extracorporeal shock wave therapy involving Computer assisted Musculoskeletal Surgical Navigational Orthopedic Procedure, Image-Guidance Based On fluoroscopic images

Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0110T

Computer assisted Musculoskeletal Surgical Navigational Orthopedic Procedure, Image-Guidance Based On CT/MRI guidance QST testing and interpretation per extremity; using touch pressure stimuli QST testing and interpretation per extremity; using vibration stimuli QST testing and interpretation per extremity; using cooling stimuli QST testing and interpretation per extremity; using heatpain stimuli QST testing and interpretation per extremity; using other stimuli

0171T (effective 10/1/2016)

New code status effective 10/1/2016 - Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level Always Investigational

0055T 0106T 0107T 0108T 0109T

0172T (effective 10/1/2016)

0159T

Updated 1/1/2017

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

New code status effective 10/1/2016 - Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List Always Investigational separately in addition to code for primary procedure) Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0174T

0175T

0198T

0200T

0201T

0202T

0203T

0204T

0205T

Updated 1/1/2017

Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure Always Investigational Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical de Percutaneous sacral augmentation (sacroplasty), bilateral injection(s), including the use of a balloon or mechanical dev Posterior vertebral joint(s) arthroplasty (eg facet joint(s) replacement) including facetectomy, laminectomy, foraminoto Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by air flow or Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, Intravascular catheter-based coronary vessel or graft spectroscopy (eg, infrared) during diagnostic evaluation and/or th

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0207T

Algorithmic analysis, remote, of electrocardiographicderived data with computer probability assessment, including repor Always Investigational Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral Always Investigational

0208T

Pure tone audiometry (threshold), automated (includes use of computer-assisted device); air only

0206T

0209T 0210T

Pure tone audiometry (threshold), automated (includes use of computer-assisted device); air and bone Speech audiometry threshold, automated (includes use of computer-assisted device);

Always Investigational

Always Investigational Always Investigational

0222T

Speech audiometry threshold, automated (includes use of computer-assisted device); with speech recognition Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated (includes use of Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s

0223T

Acoustic cardiography incl analysis of comb acoustic and electrical intervals; single w interpretation and report Always Investigational

0211T

0212T

0219T

0220T

0221T

Updated 1/1/2017

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0224T

0225T

0228T

0229T

0230T

0231T

0232T

0233T

0234T

0235T

0236T

Updated 1/1/2017

Acoustic cardiography incl analysis of comb acoustic and elec intervals; mult incl serial trended analysis and lim reprog of device parm-AV or VV delays Always Investigational Acoustic cardiography incl analysis of comb acoustic and elec intervals; mult incl serial trended analysis and lim reprog of device parm-AV and VV delays Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; ea addl level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; ea addl level Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed Skin advanced glycation endproducts measurement by multi-wavelength fluorescent spectroscopy Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel Always Investigational Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0237T

0238T

0240T

0241T

0243T

0244T 0249T

0253T

0254T

0255T

Updated 1/1/2017

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel Esophageal motility study with interpretation and report; with 3-dimensional high resolution esophageal pressure topography Esophageal motility study with interpretation and report; with stimulation or perfusion during 3-dimensional high resolution esophageal pressure topography study (eg, stimulan Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluation(s), with interpretation and report Continuous measurement of wheeze rate during treatment assessment or during sleep for documentation of nocturnal wheeze and cough for diagnostic evaluation 3 to 24 hours, with Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational Always Investigational

Always Investigational

Endovascular repair of iliac artery bifurcation using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; Always Investigational Endovascular repair of iliac artery bifurcation using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; rad Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0262T

0263T

0264T

0265T

0266T

0267T

0268T

0269T

0270T

Updated 1/1/2017

Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach (includes all congential cardiact catheterizations(s), intraprocedural contrast injection Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilater (includes intraoperative interrogation, programming, and repositioning, when pe Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intraoperative interrogation, programming, and repositioning, when Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, inra-operative interrorg Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performe

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0271T

0272T

0273T

0274T

0275T

0278T 0281T

0282T

0283T

0284T

0285T

Updated 1/1/2017

Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performe Interrogation device evaluation (in person), carotid sinus varoreflex activation system, including telemetric iterative communication with the implantable device to monitor Interrogation device evaluation (in person), carotid sinus varoreflex activation system, including telemetric iterative communication with the implantable device to monitor Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or forami Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or forami Transcutaneous Electrical Modulation Pain Reprocessing, Each Treatment Session (Includes Placement Of Electrodes) Percutaneous Transcatheter Closure Of The Left Atrial Appendage With Implant

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational Always Investigational

Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s), Subcutaneous; For Trial Always Investigational Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s), Subq; Permanent, W Pulse Generator Implant Always Investigational Revision Or Removal Of Pulse Generator Or Electrodes Including Addition Of New Electrodes, When Performed Always Investigational Electronic Analysis Of Implanted Peripheral Subcutaneous Field Stimulation Pulse Generator, With Reprog When Performed Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0286T

Near-Infrared Spectroscopy Studies Of Lower Extremity Wounds (Eg, For Oxyhemoglobin Measurement)

0287T

Near-Infrared Guidance For Vascular Access W Real-Time Digital Visualization Of Subcutaneous Vasculature Always Investigational

0288T

0291T

0292T

0293T

0294T

0299T

0300T

0301T

Updated 1/1/2017

Anoscopy, With Delivery Of Thermal Energy To The Muscle Of The Anal Canal (Eg, For Fecal Incontinence) Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, inter Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, inter Insertion of left atrial hemodynamic monitor; complete system, includes implanted communication module and pressure sensor lead in left atrium including transseptal access, ra Insertion of left atrial hemodynamic monitor; pressure sensor lead at time of insertion of pacing cardioverterdefibrillator pulse generator including radiological supervision Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature mo

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0302T

Insertion/removal and replacement of intracardiac ischemia monitoring system, complete

Always Investigational

0303T

Insertion/removal and replacement of intracardiac ischemia monitoring system, electrode only

Always Investigational

0304T

Insertion/removal and replacement of intracardiac ischemia monitoring system, device only

Always Investigational

0305T

Programming device evalulation of intracardiac ischemia monitoring system with analysis, review and report Always Investigational

0306T

Interrogation device evalulation of intracardiac ischemia monitoring system with analysis, review and report Always Investigational

0307T

Removal of intracardiac ischemia monitoring device

0309T

0310T

0311T

0312T

0313T

0314T 0315T

Updated 1/1/2017

Always Investigational

Arthrodesis, Pre-Sacral Interbody Technique, W Posterior Instrumentation, Lumbar, L4-L5 Interspace Always Investigational Motor Function Mapping Using Non-Invasive Navigated Transcranial Magnetic Stimulation (Ntms), Upper And Lower Extremity Always Investigational Non-Invasive Calculation And Analysis Of Central Arterial Pressure Waveforms With Interpretation And Report Vagus Nerve Blocking; Laparoscopic Implant Neurostim Electrode Array, Vagal Trunks, W Implantation Of Pulse Generator Vagus Nerve Blocking Therapy; Laparoscopic Revision Or Replacement Of Vagal Trunk Neurostimulator Electrode Array Vagus Nerve Blocking Therapy; Laparoscopic Removal Of Vagal Trunk Neurostimulator Electrode Array And Pulse Generator Vagus Nerve Blocking Therapy (Morbid Obesity); Removal Of Pulse Generator

Always Investigational

Always Investigational

Always Investigational

Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0317T

Vagus Nerve Blocking Therapy (Morbid Obesity); Replacement Of Pulse Generator Vagus Nerve Blocking Therapy; Neurostimulator Pulse Generator Electronic Analysis, Includes Reprogramming When Performed

0319T 0320T

Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode Insertion of subcutaneous defibrillator electrode

0316T

Always Investigational

Always Investigational

Always Investigational Always Investigational

0322T

Insertion of subcutaneous implantable defibrillator pulse generator only with existing subcutaneous electrode Always Investigational Removal of subcutaneous implantable defibrillator pulse generator only Always Investigational Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only

0323T 0324T

Always Investigational Always Investigational

0321T

0325T

Removal of subcutaneous defibrillator electrode Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator

0326T

Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) Always Investigational

0327T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable subcutaneous lead defibrillator system Always Investigational

Updated 1/1/2017

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0328T

0329T 0330T 0331T

0332T

0334T 0335T

0336T

0337T 0338T 0339T 0340T

Updated 1/1/2017

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, implantable subcutaneous lead defibrillator system Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report Tear film imaging, unilateral or bilateral, with interpretation and report Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect visualization), includes obtaining and applying autograft or allograft (structural or morselized), when performed, includes image guidance when performed (eg, CT or fluoroscopic) Extra-Osseous Subtalar Joint Implant For Talotarsal Stabilization Laparoscopy, Surgical, Ablation of Uterine Fibroids, Inc Intraop Ultrasound Guidance and Monitoring, Radiofrequency Endothelial Function Assessment, Using Peripheral Vascular Response To Reactive Hyperemia, Non-Invasive, Uni/Bilat Transcatheter Renal Sympathetic Denervation, Percutaneous Approach; Unilateral Transcatheter Renal Sympathetic Denervation, Percutaneous Approach; Bilateral Ablation, Pulmonary Tumors, Percutaneous, Cryoablation, Unilateral

Always Investigational

Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 0341T 0342T 0347T 0347T

0348T 0348T

0349T 0349T

0350T 0350T

0351T 0351T

Quantitative Pupillometry with Interpretation and Report, Unilateral or Bilateral therapeutic Apheresis with Selective Hdl Delipidation and Plasma Reinfusion Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) In bone device for RSA exam Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) RSA spine exam Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) RSA upper extermity exam Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) RSA lower extermity exam Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative Intraoperative optical breast cavity

Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational

Always Investigational Always Investigational

Always Investigational Always Investigational

Always Investigational Always Investigational

0353T 0353T

Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred Intraoperative optical breast cavity Optical coherence tomography of breast, surgical cavity; real time intraoperative Intraoperative optical breast cavity

0354T 0354T 0355T

Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred Always Investigational Intraoperative optical breast cavity Always Investigational Intraoperative optical breast cavity Always Investigational

0352T 0352T

Updated 1/1/2017

Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0356T 0356T

0358T

0376T 0377T

0378T

0379T

0380T

0381T

0382T

0383T

Updated 1/1/2017

Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each Intraoperative optical breast cavity Bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List s (iStent) Anoscopy with directed submucosal injection of bulking agent for fecal incontinence Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance enter for up to 3 Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturn External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturn External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturn

Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0391T

External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturn External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturn External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturn Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular Transcatheter removal of permanent leadless pacemaker, ventricular Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadle Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

0396T

Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure) Always Investigational

0398T

Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed

0384T

0385T

0386T 0387T 0388T

0389T

0390T

Updated 1/1/2017

Always Investigational

Always Investigational

Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0407T

Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; one to five lesions Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; six or more lesions Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed) Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement

0408T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes Always Investigational

0409T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only Always Investigational

0410T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only Always Investigational

0400T

0401T

0402T 0406T

0411T 0414T

0415T 0416T

Updated 1/1/2017

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only Removal and replacement of permanent cardiac contractility modulation system pulse generator only Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) Relocation of skin pocket for implanted cardiac contractility modulation pulse generator

Always Investigational

Always Investigational

Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational

Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0419T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system Always Investigational Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system Always Investigational Destruction neurofibromata, extensive, (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromata Always Investigational

0420T

Destruction neurofibromata, extensive, (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromata

0417T

0418T

Always Investigational

0422T 0423T

Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) Always Investigational Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral Always Investigational Secretory type II phospholipase A2 (sPLA2-IIA) Always Investigational

0424T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)

Always Investigational

0425T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only

Always Investigational

0426T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only

Always Investigational

0421T

0427T 0428T

Updated 1/1/2017

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only

Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

0430T

Removal of neurostimulator system for treatment of central sleep apnea; sensing lead only Removal of neurostimulator system for treatment of central sleep apnea; stimulation lead only

0431T

Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only

0429T

0432T 0433T

Repositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only Repositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only

Always Investigational Always Investigational

Always Investigational

Always Investigational Always Investigational

0436T

Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea Always Investigational Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session Always Investigational Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study Always Investigational

0440T - New code as of 7/1/16

Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve

0434T

0435T

0441T - New code as of 7/1/16

Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes imaging 0442T - New code as guidance; nerve plexus or other truncal nerve (eg, brachial of 7/1/16 plexus, pudendal nerve) Real time spectral analysis of prostate tissue by fluorescence spectroscopy 0443T - New code as (Use 0443T in conjunction with 55700) of 7/1/16 (Report 0443T only once per session) Initial placement of a drug-eluting ocular insert under one 0444T - New code as or more eyelids, including fitting, training, and insertion, of 7/1/16 unilateral or bilateral Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral 0445T- New code as of (For insertion and removal of drug-eluting implant into 7/1/16 lacrimal canaliculus, use 0356T)

Updated 1/1/2017

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 0446T - New code as of 1/1/17 0447T - New code as of 1/1/17

0448T - New code as of 1/1/17 0449T - New code as of 1/1/17

0450T - New code as of 1/1/17

Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure)

Always Investigational Always Investigational

Always Investigational

Always Investigational

Always Investigational

0452T - New code as of 1/1/17

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system Always Investigational nsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal Always Investigational

0453T - New code as of 1/1/17

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano-electrical skin interface Always Investigational

0451T - New code as of 1/1/17

0454T - New code as of 1/1/17

0455T - New code as of 1/1/17 0456T - New code as of 1/1/17

Updated 1/1/2017

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode Always Investigational Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes) Always Investigational Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 0457T - New code as of 1/1/17 0458T - New code as of 1/1/17

Removal of permanently implantable aortic counterpulsation ventricular assist system; mechanoelectrical skin interface Always Investigational Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode Always Investigational

0461T - New code as of 1/1/17

Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechanoelectrical skin interface and electrodes Always Investigational Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode Always Investigational Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device Always Investigational

0462T - New code as of 1/1/17

Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day Always Investigational

0463T - New code as of 1/1/17 0464T - New code as of 1/1/17 0465T - New code as of 1/1/17

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day Visual evoked potential, testing for glaucoma, with interpretation and report Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)

0459T - New code as of 1/1/17 0460T - New code as of 1/1/17

0466T - New code as of 1/1/17 0467T - New code as of 1/1/17 0468T - New code as of 1/1/17

Updated 1/1/2017

Always Investigational Always Investigational Always Investigational

Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure) This code is designated as an Add-on code by the AMA. List separately in addition to the primary procedure. Always Investigational Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator Always Investigational Removal of chest wall respiratory sensor electrode or electrode array Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 A4575 A9285 - New code as of 1/1/17 C1821 (effective 10/1/2016) C9349 C9352 C9353 C9354 C9355

C9356 C9358

C9360 C9361 C9364 C9442 C9724

C9730

C9731

C9736

Updated 1/1/2017

Topical Ox Deliver sys, nos

Always Investigational

Inversion/eversion correction device

Always Investigational

Interspinous process distraction device (implantable) Fortaderm, and Fortaderm antimicrobial, any type, per sq cm Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm

Always Investigational

Collagen nerve cuff (NeuroMatrix), per 0.5 cm length Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm SurgiMend, 0.5cm2 Dermal substitute, native, non-denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square ce Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 centimeter length Porcine implant, Permacol, per square centimeter Injection belinostat 10 mg EPS gast cardia plic Bronchoscopic bronchial thermoplasty with imaging guidance (if performed), radiofrequency ablation of airway smooth muscle, 1 lobe

Always Investigational

Bronchoscopic bronchial thermoplasty with imaging guidance (if performed), radiofrequency ablation of airway smooth muscle, 2 or more lobes

Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational

Always Investigational Laparoscopy, surgical, radiofrequency ablation of uterine fibroid(s), including intraoperative guidance and monitoring, when performed Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

C9741 E0218 E0236 E0446 E0740 E0764 E0765 E0766 E1815

E1816 E1830

E1840

E1841

G0279

G0428

G0429

Updated 1/1/2017

Right hearth catheterization with implantation of wireless pressure sensor in the pulmonary artery including any type of measurement, angiography, imaging Water Circ Cold Pad W Pump Pump For Water Circulating P Topical Ox Deliver sys, nos, includes all supplies and accessories Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer Functional neuromuscular stim Nerve Stimulator For Tx N&V Electrical stimulation device used for cancer tx, incl all accessories Dynamic adjustable ankle extension/flexion device, includes soft interface material

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Always Investigational Dynamic, adjustable toe extension/flexion device, includes soft tissue interface material Always Investigational Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material Always Investigational Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components Always Investigational Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) Commercial Always Investigational Collagen meniscus implant procedure for filling meniscal defects (eg, CMI, collagen scaffold, Menaflex) Always Investigational Dermal filler injections(s) for the treatment of facial lipodystrophy syndrome(LDS) (EG as a result of highly active antiretroviral therapy). Always Cosmetic

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017

G0460

Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment Always Investigational

G0464 G6030 G6031 G6032 G6034 G6035 G6036 G6037 G6038 G6039 G6040 G6041 G6042 G6043 G6044 G6045 G6046 G6047 G6048 G6049 G6050 G6051 G6052 G6053 G6054 G6055 G6056 G6057 M0076 P9020

Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3) Assay of amitriptyline Assay of benzodiazepines Assay of desipramine Assay of doxepin Assay of gold Assay of imipramine Assay of nortriptyline Assa of salicylate Assay of acetaminophen Alcohol (ethanol); any specimen except breath Alkaloids, urine, quantitative Assay of amphetamine or methamphetamine Assay of barbiturates, not elsewhere specified Assay of cocaine or metabolite Assay of cocaine or metabolite Assay of dihydromorphinone Assay of dihydrotestosterone Assay of dimethadione Assay of epiandrosterone Assay of ethchlorvynol Assay of flurazepam Assay of meprobamate Assay of methadone Assay of methsuximide Assay of nicotine Opiate(s), drug and metabolites, each procedure Assay of phenothiazine Prolotherapy Plaelet Rich Plasma Unit

Updated 1/1/2017

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 Q2026 Q2027 Q4103 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 Q4117 Q4118 Q4119 Q4120 Q4121 Q4122 Q4123

Injection, radiesse, 0.1 ml Injection, sculptra, 0.1 ml Oasis burn matrix, per sq cm Integra matrix, per sq cm PriMatrix, per sq cm GammaGraft, per sq cm Cymetra, injectable, 1 cc GRAFTJACKET XPRESS, injectable, 1cc Integra flowable wound matrix, injectable, 1 cc AlloSkin, per sq cm Hyalomatrix Matristem micromatrix Matristem wound matrix Matristem burn matrix Theraskin Dermacell, Per Square Centimeter Alloskin Rt, Per Square Centimeter

Always Cosmetic Always Cosmetic Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Q4124 Q4125 Q4126 Q4127 Q4128 Q4129 Q4130 Q4132 Q4133 Q4134 Q4135 Q4136 Q4137 Q4138 Q4139 Q4140 Q4141 Q4142 Q4143

Oasis Ultra Tri-Layer Matrix, per square centimeter Arthroflex, Per Square Centimeter Memoderm, Per Square Centimeter Talymed, Per Square Centimeter Flexhd Or Allopatch Hd, Per Square Centimeter Unite Biomatrix, Per Square Centimeter Strattice TM, per sq cm Grafix core Grafix prime hMatrix Mediskin EZderm Amnioexcel or biodexcel, per sq cm Biodfence dryflex, per sq cm Amniomatrix or biodmatrix, injectable, 1 cc Biodfence, per sq cm Alloskin AC, per sq cm XCM biologic tissue matrix, per sq cm Repriza, per sq cm

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Updated 1/1/2017

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 Q4145 Q4146 Q4147 Q4148 Q4149 Q4150 Q4151 Q4152 Q4153 Q4154 Q4155 Q4156 Q4157 Q4158 Q4159 Q4160 Q4161 Q4162 Q4163 Q4164 Q4165 Q4166 - New code as of 1/1/17 Q4167 - New code as of 1/1/17 Q4168 - New code as of 1/1/17 Q4169 - New code as of 1/1/17 Q4170 - New code as of 1/1/17 Q4171 - New code as of 1/1/17

Updated 1/1/2017

Epifix, injectable, 1 mg Tensix, per sq cm Architect, architect PX, or architect FX, extracellular matrix, per sq cm Neox 1k, per sq cm Excellagen, 0.1 cc Allowrap DS or dry, per sq cm Amnioband or guardian, per sq cm Dermapure, per sq cm Dermavest, per sq cm Biovance, per sq cm Neoxflo or clarixflo 1 mg Neox 100, per sq cm Revitalon, per sq cm Marigen, per sq cm Affinity, per sq cm Nushield, per square centimeter

Always Investigational Always Investigational

Bio-connekt wound matrix, per square centimeter Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5 cc Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square centimeter Helicoll, per square centimeter Keramatrix, per square centimeter Cytal, per square centimeter (Acell - full thickness diabetic ulcers, venous ulcers, etc)

Always Investigational

Truskin, per square centimeter

Always Investigational

Amnioband, 1 mg

Always Investigational

Artacent wound, per square centimeter

Always Investigational

Cygnus, per square centimeter

Always Investigational

Interfyl, 1 mg

Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Procedures and services considered always investigational or cosmetic Moda Health Commercial Group and Individual Members Updated 1/1/2017 Q4172 - New code as of 1/1/17 Q4173 - New code as of 1/1/17 Q4174 - New code as of 1/1/17 Q4175 - New code as of 1/1/17 S1090

Puraply or puraply am, per square centimeter

Always Investigational

Palingen or palingen xplus, per square centimeter

Always Investigational

Palingen or promatrx, 0.36 mg per 0.25 cc

Always Investigational

Miroderm, per square centimeter

Always Investigational

Mometasone furoate sinus implant, 370 micrograms

Always Investigational

S2350

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar Always Investigational Decompress disc RF lumbar Always Investigational Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace Always Investigational

S2351 S3650

Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace (list separately in addition to code for primary procedure) Always Investigational Saliva test, hormone level; during menopause Always Investigational

S2348 S2348

S3652 S3721 S3722 S3890 S8040 S8930

S8948 S9090

Updated 1/1/2017

Saliva test, hormone level; to assess preterm labor risk Prostate cancer antigen (PCA3) testing Dose Optimization By Area Under The Curve (Auc) Analysis, For Infusional 5-Fluorouracil Fecal DNA analysis Topographic Brain Mapping Auricular electrostimulation Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes Vertebral Axial Decompressio

Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational Always Investigational

Always Investigational Always Investigational