Preauthorization Requirement Changes Starting Jan. 1, 2024

0420U

Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma

0421U

Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers (GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2) and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk

0422U

Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate

0423U

Psychiatry (e.g., depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition

0424U

Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer

0425U

Genome (e.g., unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (e.g., parents, siblings)

0426U

Genome (e.g., unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis

0428U

Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden

0433U

Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer

0434U

Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes

0437U

Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score

0438U

Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions

33276

Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed

33277

Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure)

33278

Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s)

33279

Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only

33280

Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only

33281

Repositioning of phrenic nerve stimulator transvenous lead(s)

33287

Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator

33288

Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s)

61889

Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s)

61891

Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s)

61892

Removal of skull-mounted cranial neurostimulator pulse generator or receiver with cranioplasty, when performed

64596

Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array

64597

Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array (List separately in addition to code for primary procedure)

64598

Revision or removal of neurostimulator electrode array, peripheral nerve, with integrated neurostimulator

75580

Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional

81457

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability

81458

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability

81459

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

81462

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (e.g., plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements

81463

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (e.g., plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability

81464

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (e.g., plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

A6520

Gradient compression garment, glove, padded, for nighttime use, each

A6521

Gradient compression garment, glove, padded, for nighttime use, custom, each

A6522

Gradient compression garment, arm, padded, for nighttime use, each

A6523

Gradient compression garment, arm, padded, for nighttime use, custom, each

A6524

Gradient compression garment, lower leg and foot, padded, for nighttime use, each

A6525

Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each

A6526

Gradient compression garment, full leg and foot, padded, for nighttime use, each

A6527

Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each

A6528

Gradient compression garment, bra, for nighttime use, each

A6529

Gradient compression garment, bra, for nighttime use, custom, each

A6552

Gradient compression stocking, below knee, 30 – 40 mmhg, each

A6553

Gradient compression stocking, below knee, 30 – 40 mmhg, custom, each

A6554

Gradient compression stocking, below knee, 40 mmhg or greater, each

A6555

Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

A6556

Gradient compression stocking, thigh length, 18 – 30 mmhg, custom, each

A6557

Gradient compression stocking, thigh length, 30 – 40 mmhg, custom, each

A6558

Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

A6559

Gradient compression stocking, full length/chap style, 18 – 30 mmhg, custom, each

A6560

Gradient compression stocking, full length/chap style, 30 – 40 mmhg, custom, each

A6561

Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each

A6562

Gradient compression stocking, waist length, 18 – 30 mmhg, custom, each

A6563

Gradient compression stocking, waist length, 30 – 40 mmhg, custom, each

A6564

Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

A6565

Gradient compression gauntlet, custom, each

A6566

Gradient compression garment, neck/head, each

A6567

Gradient compression garment, neck/head, custom, each

A6568

Gradient compression garment, torso and shoulder, each

A6569

Gradient compression garment, torso/shoulder, custom, each

A6570

Gradient compression garment, genital region, each

A6571

Gradient compression garment, genital region, custom, each

A6572

Gradient compression garment, toe caps, each

A6573

Gradient compression garment, toe caps, custom, each

A6574

Gradient compression arm sleeve and glove combination, custom, each

A6575

Gradient  compression arm sleeve and glove combination, each

A6576

Gradient  compression arm sleeve, custom, medium weight, each

A6577

Gradient  compression arm sleeve, custom, heavy weight, each

A6578

Gradient  compression arm sleeve, each

A6579

Gradient compression glove, custom, medium weight, each

A6580

Gradient  compression glove, custom, heavy weight, each

A6581

Gradient compression glove, each

A6582

Gradient compression gauntlet, each

A6583

Gradient compression wrap with adjustable straps, below knee, 30 – 50 mmhg, each

A6584

Gradient compression wrap with adjustable straps, not otherwise specified

A6585

Gradient pressure wrap with adjustable straps, above knee, each

A6586

Gradient pressure wrap with adjustable straps, full leg, each

A6587

Gradient pressure wrap with adjustable straps, foot, each

A6588

Gradient pressure wrap with adjustable straps, arm, each

A6589

Gradient pressure wrap with adjustable straps, bra, each

A6593

Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6594

Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each

A6595

Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each

A6596

Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each

A6597

Gradient compression bandage roll, elastic long stretch, linear yard, any width, each

A6598

Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each

A6599

Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each

A6600

Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each

A6601

Gradient compression bandaging supply, high density foam pad, any size or shape, each

A6602

Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each

A6603

Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each

A6604

Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each

A6605

Gradient compression bandaging supply, padded foam, per linear yard, any width, each

A6606

Gradient compression bandaging supply, padded textile, per linear yard, any width, each

A6607

Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each

A6608

Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each

A6609

Gradient compression bandaging supply, not otherwise specified

A6610

Gradient compression stocking, below knee, 18-30 mmhg, custom, each

E0678

Non-pneumatic sequential compression garment, full leg

E0679

Non-pneumatic sequential compression garment, half leg

E0680

Non-pneumatic compression controller with sequential calibrated gradient pressure

E0681

Non-pneumatic compression controller without calibrated gradient pressure

E0682

Non-pneumatic sequential compression garment, full arm

E2001

Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system

L3161

Foot, adductus positioning device, adjustable

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control

L5926

Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type