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UnitedHealthcare® Medicare Advantage Policy Guideline CATEGORY III CPT CODES Guideline Number: MPG043.05 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 2 REFERENCES .......................................................... 19 GUIDELINE HISTORY/REVISION INFORMATION .......... 24 Approval Date: March 15, 2017 Related Policies See References INSTRUCTIONS FOR USE This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates for health care services submitted on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be accurate and current as of the date of publication. This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member eligibility, any federal or state regulatory requirements, Centers for Medicare and Medicaid Services (CMS) policy, the member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document may differ greatly from the standard benefit plan upon which this Policy Guideline is based. In the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary. UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines to comply with changes in CMS policy. UnitedHealthcare encourages physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. This Policy Guideline is provided for informational purposes. It does not constitute medical advice. POLICY SUMMARY Overview The American Medical Association (AMA) developed Category III CPT codes to track the utilization of emerging technologies, services, and procedures. The Category III CPT codes description does not establish a service or procedure as safe, effective or applicable to the clinical practice of medicine. The development and coverage guidelines in this policy were based on a review of pertinent medical literature, policies from other Medicare contractors, and discussions with appropriate specialists. Title XVIII of the Social Security Act, Section 1862(a) (1) (A) allows coverage and payment for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Because of the specific purpose these Category III codes serve, UnitedHealthcare will consider the item, service, or procedure represented by these codes to be not proven effective; therefore, the codes will be denied as not medically necessary, unless an LCD or coverage article specifically extending coverage to a particular Category III code has been published. If providers believe that any of the Category III codes qualify for Medicare coverage (have been proven both-safe and effective as well as reasonable and necessary), those providers may request their removal from this list through the standard reconsideration process. Copies of the extended coverage details must be submitted with the reconsideration. Guidelines Unless an NCD, LCD or coverage article is published to address coverage for a specific Category III CPT code, UnitedHealthcare considers all services and procedures listed in the current and future Category III CPT code list as not proven effective and will deny submitted claims as not medically necessary. Category III CPT Codes Page 1 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but are determined to be any of the following: Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used Not proven to be safe and effective based on peer review or scientific literature Experimental Not medically necessary in the particular case Furnished at a level, duration or frequency that is not medically appropriate Not furnished in accordance with accepted standards of medical practice, or Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition. Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be: Consistent with the symptoms or diagnosis of the illness or injury under treatment; Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or investigational); Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; Furnished at the most appropriate level that can be provided safely and effectively to the patient. Medical devices that are not approved for marketing by the Food and Drug Administration (FDA) are considered investigational by Medicare and are not considered reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve functioning of a malformed body member. UnitedHealthcare payment, therefore, may not be made for medical procedures and services performed using devices that have not been approved for marketing by the FDA or for those not included in an FDA-approved investigational (IDE) trial. APPLICABLE CODES The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. CPT Code Noncovered Description 0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) (See Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures) 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) (See Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures) 0058T Cryopreservation; reproductive tissue, ovarian 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue 0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue 0085T Breath test for heart transplant rejection (Not Covered by Medicare) [See Policy Guideline titled Heartsbreath Test for Heart Transplant Rejection (NCD 260.10)] 0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) 0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) Category III CPT Codes Page 2 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered 0101T 0102T Description Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy [See Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)] Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle [See Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)] 0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation 0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation 0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia 0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia 0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation 0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes 0126T Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment 0159T 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) 0174T 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) 0175T 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 0178T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report 0179T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and graphics only, without interpretation and report 0180T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; interpretation and report only 0188T Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (Not Covered by Medicare) 0189T Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) (Not Covered by Medicare) 0190T Placement of intraocular radiation source applicator (List separately in addition to primary procedure) 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace 0196T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure) Category III CPT Codes Page 3 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0198T Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report 0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine 0205T Intravascular catheter-based coronary vessel or graft spectroscopy (e.g., infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure) 0206T Algorithmic analysis, remote, of electrocardiographic-derived data with computer probability assessment, including report 0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral 0208T Pure tone audiometry (threshold), automated; air only 0209T Pure tone audiometry (threshold), automated; air and bone 0210T Speech audiometry threshold, automated; 0211T Speech audiometry threshold, automated; with speech recognition 0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) (See Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections) 0219T Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical 0220T Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic 0221T Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar Category III CPT Codes Page 4 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered 0222T 0228T 0229T Description Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level (See Policy Guideline titled Epidural Injection) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) (See Policy Guideline titled Epidural Injection) 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level (See Policy Guideline titled Epidural Injection) 0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) (See Policy Guideline titled Epidural Injection) 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed 0234T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery 0235T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel 0236T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta 0237T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel 0254T Endovascular repair of iliac artery bifurcation (e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; 0255T Endovascular repair of iliac artery bifurcation (e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; radiological supervision and interpretation 0263T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest 0264T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest 0265T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy 0266T Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative interrogation, programming, and repositioning, when performed) 0267T Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 0268T Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) Category III CPT Codes Page 5 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0269T Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) 0270T Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 0271T Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) 0272T Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) 0273T Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic 0278T Transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes) 0290T Corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar keratoplasty (List separately in addition to code for primary procedure) 0293T Insertion of left atrial hemodynamic monitor; complete system, includes implanted communication module and pressure sensor lead in left atrium including transseptal access, radiological supervision and interpretation, and associated injection procedures, when performed 0294T 0299T 0300T Insertion of left atrial hemodynamic monitor; pressure sensor lead at time of insertion of pacing cardioverter-defibrillator pulse generator including radiological supervision and interpretation and associated injection procedures, when performed (List separately in addition to code for primary procedure) Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound [See Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)] Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) [See Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)] 0301T Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermotherapy guidance 0302T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system (includes device and electrode) 0303T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; electrode only Category III CPT Codes Page 6 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0304T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; device only 0305T Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report 0306T Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report 0307T Removal of intracardiac ischemia 0309T Arthrodesis, pre-sacral interbody technique, w/ disc space prep, discectomy 0310T Motor function mapping using non-invasive navigated transcranial magnetic stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity 0312T Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming 0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator 0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator 0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator 0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator 0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed 0329T Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report 0330T Tear film imaging, unilateral or bilateral, with interpretation and report 0333T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT [See Policy Guideline titled Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)] Visual evoked potential, screening of visual acuity, automated, with report 0335T Extra-osseous subtalar joint implant for talotarsal stabilization 0337T Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (e.g., brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral 0338T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral 0339T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral 0340T Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance 0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral 0342T Therapeutic apheresis with selective HDL delipidation and plasma reinfusion 0346T Ultrasound, elastography (List separately in addition to code for primary procedure) 0331T 0332T Category III CPT Codes Page 7 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0347T Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) 0348T Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) 0349T Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) 0350T Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) 0351T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative 0352T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred 0353T Optical coherence tomography of breast, surgical cavity; real time intraoperative 0354T 0355T 0356T Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon, with interpretation and report (See Policy Guideline titled Capsule Endoscopy) Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each 0357T Cryopreservation; immature oocyte(s) 0358T Bioelectrical impedance analysis whole body composition assessment, with interpretation and report 0359T Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report 0360T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient 0361T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (List separately in addition to code for primary service) 0362T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient 0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient (List separately in addition to code for primary procedure) 0364T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time 0365T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) 0366T Group adaptive behavior treatment by protocol, administered by technician, face-toface with two or more patients; first 30 minutes of technician time 0367T Group adaptive behavior treatment by protocol, administered by technician, face-toface with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Category III CPT Codes Page 8 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0368T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time 0369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure) 0370T Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) 0371T Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) 0372T Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients 0373T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient 0374T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure) 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels (Effective 01/01/2015) 0377T Anoscopy with directed submucosal injection of bulking agent for fecal incontinence (Effective 01/01/2015) 0380T Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report (Effective 01/01/2015) 0381T 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 nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional (Effective 01/01/2015) 0382T 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 nocturnal epilepsy seizure events; review and interpretation only (Effective 01/01/2015) 0383T External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional (Effective 01/01/2015) 0384T External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only (Effective 01/01/2015) 0385T External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional (Effective 01/01/2015) 0386T External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only (Effective 01/01/2015) Category III CPT Codes Page 9 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. CPT Code Noncovered Description 0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular (Effective 01/01/2015) 0388T Transcatheter removal of permanent leadless pacemaker, ventricular (Effective 01/01/2015) 0389T 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, leadless pacemaker system (Effective 01/01/2015) 0390T 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, leadless pacemaker system (Effective 01/01/2015) 0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system (Effective 01/01/2015) 0396T Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure) (Effective 01/01/2016) 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure) (Effective 01/01/2016) 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 (Effective 01/01/2016) 0399T Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics) (List separately in addition to code for primary procedure) (Effective 01/01/2016) 0400T 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 (Effective 01/01/2016) 0401T 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 (Effective 01/01/2016) 0402T Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed) (Effective 01/01/2016) 0403T Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day (Effective 01/01/2016) 0404T Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency (Effective 01/01/2016) 0405T Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-to-face time (Effective 01/01/2016) 0406T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant (Effective 01/01/2016) 0407T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement (Effective 01/01/2016) 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 (Effective 01/01/2016) 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 (Effective 01/01/2016) Category III CPT Codes Page 10 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Noncovered Description 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 (Effective 01/01/2016) 0411T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only (Effective 01/01/2016) 0412T Removal of permanent cardiac contractility modulation system; pulse generator only (Effective 01/01/2016) 0413T Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) (Effective 01/01/2016) 0414T Removal and replacement of permanent cardiac contractility modulation system pulse generator only (Effective 01/01/2016) 0415T Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) (Effective 01/01/2016) 0416T Relocation of skin pocket for implanted cardiac contractility modulation pulse generator (Effective 01/01/2016) 0417T 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 (Effective 01/01/2016) 0418T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system (Effective 01/01/2016) 0419T Destruction of neurofibroma, extensive, (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas(Effective 01/01/2016) 0420T Destruction of neurofibroma, extensive, (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas (Effective 01/01/2016) 0421T 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) (Effective 01/01/2016) 0422T Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral (Effective 01/01/2016) 0423T Secretory type II phospholipase A2 (sPLA2-IIA) (Effective 01/01/2016) 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) (Effective 01/01/2016) 0425T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only (Effective 01/01/2016) 0426T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only (Effective 01/01/2016) 0427T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only (Effective 01/01/2016) 0428T Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only (Effective 01/01/2016) 0429T Removal of neurostimulator system for treatment of central sleep apnea; sensing lead only (Effective 01/01/2016) 0430T Removal of neurostimulator system for treatment of central sleep apnea; stimulation lead only (Effective 01/01/2016) 0431T Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only (Effective 01/01/2016) Category III CPT Codes Page 11 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Noncovered Description 0432T Repositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only (Effective 01/01/2016) 0433T Repositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only (Effective 01/01/2016) 0434T Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea (Effective 01/01/2016) 0435T Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session (Effective 01/01/2016) 0436T Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study (Effective 01/01/2016) 0437T Implantation of non-biologic or synthetic implant (e.g., polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure) (Effective 07/01/2016) 0438T Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance (Effective 07/01/2016) 0439T Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure) (Effective 07/01/2016) 0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve (Effective 07/01/2016) 0441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve (Effective 07/01/2016) 0442T Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (e.g., brachial plexus, pudendal nerve) (Effective 07/01/2016) 0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance (List separately in addition to code for primary procedure) (Effective 07/01/2016) 0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral (Effective 07/01/2016) 0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral (Effective 07/01/2016) 0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training (Effective 01/01/2017) 0447T Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision (Effective 01/01/2017) 0448T Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation (Effective 01/01/2017) 0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device (Effective 01/01/2017) 0450T 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) (Effective 01/01/2017) 0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes) (Effective 01/01/2017) 0452T Insertion 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 (Effective 01/01/2017) Category III CPT Codes Page 12 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Noncovered Description 0453T 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 (Effective 01/01/2017) 0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode (Effective 01/01/2017) 0455T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes) (Effective 01/01/2017) 0456T Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal (Effective 01/01/2017) 0457T Removal of permanently implantable aortic counterpulsation ventricular assist system; mechano-electrical skin interface (Effective 01/01/2017) 0458T Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode (Effective 01/01/2017) 0459T Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano-electrical skin interface and electrodes (Effective 01/01/2017) 0460T Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode (Effective 01/01/2017) 0461T Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device (Effective 01/01/2017) 0462T 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 (Effective 01/01/2017) 0463T 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 (Effective 01/01/2017) 0464T Visual evoked potential, testing for glaucoma, with interpretation and report (Effective 01/01/2017) 0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication) (Effective 01/01/2017) 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure) (Effective 01/01/2017) 0467T Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator (Effective 01/01/2017) 0468T Removal of chest wall respiratory sensor electrode or electrode array (Effective 01/01/2017) Provisional Coverage 0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy [See Policy Guideline titled Artificial Hearts and Related Devices (NCD 20.9)] 0052T Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) [See Policy Guideline titled Artificial Hearts and Related Devices (NCD 20.9)] 0053T Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit [See Policy Guideline titled Artificial Hearts and Related Devices (NCD 20.9)] 0075T Transcatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; initial vessel Category III CPT Codes Page 13 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Provisional Coverage Description 0076T Transcatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; each additional vessel (List separately in addition to code for primary procedure) 0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy (See Policy Guideline titled Retinal Prosthesis) 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure) [See Policy Guideline titled Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)] 0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) [See Policy Guideline titled Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)] 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) [See Policy Guideline titled Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)] 0184T Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS), including muscularis propria (i.e., full thickness) (See Policy Guideline titled Excision of Rectal Tumor) 0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion (See Policy Guideline titled Anterior Segment Aqueous Drainage Device) 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed [See Policy Guideline titled Vertebral Augmentation Procedure (VAP)/Percutaneous Vertebroplasty] 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed [See Policy Guideline titled Vertebral Augmentation Procedure (VAP)/Percutaneous Vertebroplasty] 0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space (See Policy Guideline titled Anterior Segment Aqueous Drainage Device) 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (See Policy Guidelines titled Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (NCD 150.13)] 0295T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation (See Policy Guideline titled External Electrocardiographic Recording) 0296T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording) (See Policy Guideline titled External Electrocardiographic Recording) 0297T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report (See Policy Guideline titled External Electrocardiographic Recording) 0298T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation (See Policy Guideline titled External Electrocardiographic Recording) 0308T Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis (See Policy Guideline titled Ocular Telescope) Category III CPT Codes Page 14 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Provisional Coverage Description 0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus [See Policy Guideline titled Transcatheter Mitral Valve Repair (TMVR) (NCD 20.33)] 0376T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) (Effective 01/01/2015) (See Policy Guideline titled Anterior Segment Aqueous Drainage Device) Possible Provisional Coverage 0378T 0379T 0394T 0395T Codes No Longer 0249T 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 30 days; review and interpretation with report by a physician or other qualified health care professional (Effective 01/01/2015) (See Policy Guideline titled TBD) 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 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional (Effective 01/01/2015) (See Policy Guideline titled TBD) High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed (Effective 01/01/2016) (See Policy Guideline titled High Dose Rate Electronic Brachytherapy) High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed (Effective 01/01/2016) (See Policy Guideline titled High Dose Rate Electronic Brachytherapy) Considered Investigational; Global Coverage Allowed Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance Expired Codes 0019T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy [See Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)] (Expired 12/31/2016 – See 20999) 0059T Cryopreservation; oocyte(s) (Expired 12/31/2014 – See 89337, 0357T) 0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session (Expired 12/31/2014 – See G6016) (See Policy Guideline titled Delivery of IMRT/SRS/SBRT) 0092T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure) (Expired 12/31/2014 – To report cervical arthroplasty on three levels or more, see 0375T) 0099T Implantation of intrastromal corneal ring segments (Expired 12/31/2015 – See 65785) (See Policy Guideline titled Intrastromal Corneal Ring Segments) 0103T Holotranscobalamin, quantitative (Expired 12/31/2015 – See 84999) 0123T Fistulization of sclera for glaucoma, through ciliary body (Expired 12/31/2015 – See 66999) 0169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) (Expired 12/31/2016 – See 64999) 0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level (Expired 12/31/2016 – See 22867, 22869) Category III CPT Codes Page 15 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Expired Codes Description 0172T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure) (See Policy Guideline titled Insertion of Posterior Spinous Process Device) (Expired 12/31/2016 – See 22868, 22870) 0181T Corneal hysteresis determination, by air impulse stimulation, bilateral, with interpretation and report (Expired 12/31/2014 – See 92145) 0182T High dose rate electronic brachytherapy, per fraction (Expired 12/31/2015 – See 0394T, 0395T) (See Policy Guideline titled High Dose Rate Electronic Brachytherapy) 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment (Expired 12/31/2014 – See G6017) (See Policy Guideline titled Delivery of IMRT/SRS/SBRT) 0199T Physiologic recording of tremor using accelerometer(s) and/or gyroscope(s) (including frequency and amplitude) including interpretation and report (Expired 12/31/2014 – See 95999) 0223T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; single, with interpretation and report (Expired 12/31/2015 – See 93799) 0224T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter, AV or VV delays only, with interpretation and report (Expired 12/31/2015 – See 93799) 0225T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter, AV and VV delays, with interpretation and report (Expired 12/31/2015 – See 93799) 0226T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when performed (Expired 12/31/2014 – See G6027) (See Policy Guideline titled High Resolution Anoscopy) 0227T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); with biopsy(ies) (Expired 12/31/2014 – See G6028) (See Policy Guideline titled High Resolution Anoscopy) 0233T Skin advanced glycation endproducts (AGE) measurement by multi-wavelength fluorescent spectroscopy (Expired 12/31/2015 – See 88749) 0239T Bioimpedance spectroscopy (BIS), measuring 100 frequencies or greater, direct measurement of extracellular fluid differences between the limbs (Expired 12/31/2014 – See 93702) 0240T Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with high resolution esophageal pressure topography (Expired 12/31/2015 – See 91299) [See Policy Guideline titled Esophageal Manometry (NCD 100.4)] 0241T Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion during high resolution esophageal pressure topography study (e.g., stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure) (Expired 12/31/2015 – See 91299) [See Policy Guideline titled Esophageal Manometry (NCD 100.4)] 0243T Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluation(s), with interpretation and report (Expired 12/31/2015 – See 94799) 0244T 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 interpretation and report (Expired 12/31/2015 – See 94799) Category III CPT Codes Page 16 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Expired Codes Description 0245T Open treatment of rib fracture requiring internal fixation, unilateral; 1-2 ribs (Expired 12/31/2014 – See 21811) 0246T Open treatment of rib fracture requiring internal fixation, unilateral; 3-4 ribs (Expired 12/31/2014 – See 21811, 21812) 0247T Open treatment of rib fracture requiring internal fixation, unilateral; 5-6 ribs (Expired 12/31/2014 – See 21812) 0248T Open treatment of rib fracture requiring internal fixation, unilateral; 7 or more ribs (Expired 12/31/2014 – See 21813) 0262T Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach (Expired 12/31/2015 – See 33477) 0281T Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation [See Policy Guideline titled Percutaneous Left Atrial Appendage Closure (LAAC) (NCD 20.34)] (Expired 12/31/2016 – See 33340) 0282T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period [See Policy Guideline titled Electrical Nerve Stimulators (NCD 160.7)] (Expired 12/31/2016 – See 64999) 0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator [See Policy Guideline titled Electrical Nerve Stimulators (NCD 160.7)] (Expired 12/31/2016 – See 64999) 0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed [See Policy Guideline titled Electrical Nerve Stimulators (NCD 160.7)] (Expired 12/31/2016 – See 64999) 0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed (Expired 12/31/2016 – See 64999) 0286T Near-infrared spectroscopy studies of lower extremity wounds (e.g., for oxyhemoglobin measurement) (Expired 12/31/2016 – See 76499) 0287T 0288T 0289T Near-infrared guidance for vascular access requiring real-time digital visualization of subcutaneous vasculature for evaluation of potential access sites and vessel patency (Expired 12/31/2016) Anoscopy, with delivery of thermal energy to the muscle of the anal canal (e.g., for fecal incontinence) [See Policy Guideline titled Electrical Continence Aid (NCD 230.15)] (Expired 12/31/2016 – See 46999) Corneal incisions in the donor cornea created using a laser, in preparation for penetrating or lamellar keratoplasty (List separately in addition to code for primary procedure) (Expired 12/31/2016) 0291T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel (List separately in addition to primary procedure) (Expired 12/31/2016 – See 92978, 92979) 0292T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; each additional vessel (List separately in addition to primary procedure) (Expired 12/31/2016 – See 92978, 9 2979) 0311T Non-invasive calculation and analysis of central arterial pressure waveforms with interpretation and report (Expired 12/31/2015 – See 93050) Category III CPT Codes Page 17 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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CPT Code Expired Codes Description 0319T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode (Expired 12/31/2014 – See 33270) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0320T Insertion of subcutaneous defibrillator electrode (Expired 12/31/2014 – See 33271) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0321T Insertion of subcutaneous implantable defibrillator pulse generator only with existing subcutaneous electrode (Expired 12/31/2014 – See 33240) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0322T Removal of subcutaneous implantable defibrillator pulse generator only (Expired 12/31/2014 – See 33241) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0323T Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only (Expired 12/31/2014 – See 33262-33264) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0324T Removal of subcutaneous defibrillator electrode (Expired 12/31/2014 – See 33272) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0325T Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator (Expired 12/31/2014 – See 33273) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0326T Electrophysiologic evaluation of subcutaneous implantable defibrillator (Expired 12/31/2014 – See 93644) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0327T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system (Expired 12/31/2014 – See 93261) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0328T 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 (Expired 12/31/2014 – See 93260) [See Policy Guideline titled Implantable Automatic Defibrillators (NCD 20.4)] 0334T 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 (e.g., CT or fluoroscopic) (Expired 12/31/2014 – See 27279) 0336T Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency (Expired 12/31/2016 – See 58674) 0343T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis (Expired 12/31/2014 – See 33418) 0344T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) (Expired 12/31/2014 – See 33419) 0392T Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band) (Effective 07/01/2015) (Expired 12/31/2016 – See 43284) 0393T Removal of esophageal sphincter augmentation device (Effective 07/01/2015) (Expired 12/31/2016 – See 43285) CPT® is a registered trademark of the American Medical Association Category III CPT Codes Page 18 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. REFERENCES CMS Local Coverage Determinations (LCDs) LCD Medicare Part A L33392 (Category III CPT® Codes) CT, IL, MA, ME, MN, NH, NY, RI, VT, NGS WI Medicare Part B CT, IL, MA, ME, MN, NH, NY, RI, VT, WI L36219 (Non Covered Services) Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L35008 (Non-Covered Services) Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY L33777 (Noncovered Services) First Coast FL, PR, VI FL, PR, VI L35094 (Services That Are Not Reasonable and Necessary) Novitas AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX L34370 (Category III CPT® Codes) CGS KY, OH KY, OH L35490 (Category III Codes) WPS AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY KS, IA, MO, NE, MI, IN L33538 (Radiation Therapy for T1 Basal Cell and Squamous Cell Carcinomas of the Skin) First Coast Fl, PR, VI Fl, PR, VI L34106 (Percutaneous Vertebral Augmentation) Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY L34228 (Percutaneous Vertebral Augmentation) Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L34300 (Surgery: Vertebral Augmentation Procedures (VAPs) Cahaba AL, GA, TN AL, GA, TN L34293 (Surgery: Lumbar Facet Blockade) Cahaba AL, GA, TN AL, GA, TN L34291 (Surgery: Injections of the Spinal Canal) Cahaba AL, GA, TN AL, GA, TN L34892 (Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections) Novitas AR, CO, DC, DE, LA, MS, MD, PA, NJ, NM, OK, TX AR, CO, DC, DE, LA, MS, MD, PA, NJ, NM, OK, TX L34328 (Peripheral Nerve and Peripheral Nerve Field Stimulation) Noridian AS, CA, GU, HI, MP, NV L34636 (Electrocardiographic (EKG or ECG) Monitoring (Holter or RealTime Monitoring)) WPS AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY IA, IN, KS, MI, MO, NE L33380 (Long-Term Wearable Electrocardiographic Monitoring (WEM)) First Coast FL, PR, VI FL, PR, VI L33584 (Implantable Miniature Telescope (IMT)) NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI CT, IL, MA, ME, MN, NH, NY, RI, VT, WI L33377 (Implantable Miniature Telescope (IMT)) First Coast FL, PR, VI FL, PR, VI L35627 (Extracorporeal Shock Wave Lithotripsy for Musculoskeletal Conditions) Palmetto NC, SC, VA, WV NC, SC, VA, WV Category III CPT Codes Page 19 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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LCD L34555 (Non-Covered Category III CPT Codes) Palmetto Medicare Part A Medicare Part B NC, SC, VA, WV L34892 (LCD Title Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections) Novitas AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX L36232 (Diagnostic Evaluation and Medical Management of ModerateSevere Dry Eye Disease (DED)) First Coast FL, PR, VI FL, PR, VI L35087 (Glaucoma Treatment with Aqueous Drainage Device) Novitas Retired 08/11/2016 AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX L34184 (Percutaneous Vertebral Augmentation) Noridian Retired 07/14/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L34168 (Percutaneous Vertebral Augmentation) Noridian Retired 07/14/2016 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY L36217 (Non-Covered Services) Noridian Retired 07/14/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L34886 (Non-Covered Services) Noridian Retired 07/14/2016 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY L34065 (Brachytherapy: NonIntracoronary) Noridian Retired 04/01/2016 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY L34527 (Ablative Therapy) WPS Retired 04/01/2016 AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY IA, IN, KS, MI, MO, NE L33439 (Paravertebral Facet Joint Block) Palmetto Retired 02/14/2016 NC, SC, VA, WV NC, SC, VA, WV L35956 (Left Atrial Appendage Closure or Occlusion) NGS Retired 02/08/2016 CT, IL, MA, ME, MN, NH, NY, RI, VT, WI CT, IL, MA, ME, MN, NH, NY, RI, VT, WI CMS Articles Article A54740 (Noncovered services revision to the Part A-B LCD) First Coast A52928 (Sources of Information and Basis for Decision Noncovered Services LCD) First Coast Medicare Part A FL, PR, VI FL, PR, VI FL, PR, VI A54699 (Non-Coverage of 0075T) Noridian A54698 (Non-Coverage of 0075T) Noridian Medicare Part B FL, PR, VI AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY A54697 (Non-Coverage of 0075T) Noridian AS, CA, GU, HI, MP, NV A54696 (Non-Coverage of 0075T) Noridian AS, CA, GU, HI, MP, NV A52693 (Educational Article - CPT 0171T and 0172T (Insertion of posterior spinous process distraction device)) Cahaba AL, GA, TN AL, GA, TN Category III CPT Codes Page 20 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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Article A52702 (Educational Article Insertion of anterior segment aqueous drainage device, without extraocular reservoir) Cahaba Medicare Part A A52922 (Injectable Bulking Agents for the Treatment of Fecal Incontinence) Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY Medicare Part B AL, GA, TN A52923 (Injectable Bulking Agents for the Treatment of Fecal Incontinence) Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY A52921 (Injectable Bulking Agents for the Treatment of Fecal Incontinence) Noridian AS, CA, GU, HI, MP, NV A52920 (Injectable Bulking Agents for the Treatment of Fecal Incontinence) Noridian AS, CA, GU, HI, MP, NV A52375 (Category III CPT® Code Coverage) CGS KY, OH A53044 (ArgusM II Retinal Prosthesis System) Palmetto KY, OH NC, SC, VA, WV A54327 (ArgusM II Retinal Prosthesis System) CGS KY, OH KY, OH A52419 (Ocular Blood Flow Tests – Medical Policy Article) NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI CT, IL, MA, ME, MN, NH, NY, RI, VT, WI A53006 (Hemorrhoid Artery Ligation CPT Code 0249T Article) Palmetto NC, SC, VA, WV A52702 (Educational Article Insertion of anterior segment aqueous drainage device, without extraocular reservoir) Cahaba AL, GA, TN A53501 (Implantable Miniature Telescope (IMT) for Macular Degeneration) Palmetto NC, SC, VA, WV A55105 (Noncovered services revision to the Part A and Part B LCD) First Coast FL, PR, VI A54836 (2016 HCPCS local coverage determination changes) First Coast FL, PR, VI A54837 (2016 HCPCS local coverage determination changes Part B) First Coast A55348 (2017 ICD-10-CM Coding Changes Part A) First Coast FL, PR, VI FL, PR, VI A55350 (2017 ICD-10-CM Coding Changes Part B) First Coast A53258 (Radiofrequency Ablation of Uterine Fibroids) Noridian Retired 12/22/2016 FL, PR, VI AS, CA, GU, HI, MP, NV A53260 (Radiofrequency Ablation of Uterine Fibroids) Noridian Retired 12/22/2016 A53262 (Radiofrequency Ablation of Uterine Fibroids) Noridian Retired 12/22/2016 FL, PR, VI AS, CA, GU, HI, MP, NV AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY Category III CPT Codes Page 21 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. 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Article A53264 (Radiofrequency Ablation of Uterine Fibroids) Noridian Retired 12/22/2016 Medicare Part A Medicare Part B AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY A52857 (Implantable Miniature Telescope (IMT) – Supplemental Instructions Article) NGS Retired 05/01/2016 CT, IL, MA, ME, MN, NH, NY, RI, VT, WI CT, IL, MA, ME, MN, NH, NY, RI, VT, WI A52797 (CPT Category III Non Covered and Covered Codes) Noridian Retired 03/01/2016 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY A52796 (CPT Category III Non Covered and Covered Codes) Noridian Retired 03/01/2016 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY A52794 (Coverage and NonCoverage of CPT Category III Codes) Noridian Retired 03/01/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV A52792 (Coverage and NonCoverage of CPT Category III Codes) Noridian Retired 03/01/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV A54304 (Response to Comments: Non-Covered Services Policy, L35238) Noridian Retired 01/09/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV A54305 (Response to Comments: Non-Covered Services Policy, L35212) Noridian Retired 01/09/2016 AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV CMS Transmittals Transmittal 2717, Change (ASC) Payment System) Transmittal 2718, Change Payment System (OPPS)) Transmittal 2970, Change (ASC) Payment System) Transmittal 2971, Change Payment System (OPPS)) Transmittal 3279, Change (ASC) Payment System) Transmittal 3280, Change Payment System (OPPS)) Transmittal 3523, Change Payment System (OPPS)) Transmittal 3531, Change (ASC) Payment System) MLN Matters Article MM7008, Article MM7443, Article MM7854, Article MM8328, Article MM8338, Article MM8776, Article MM8786, Article MM9205, Article MM9207, Article MM9658, Article MM9668, July July July July July July July July July July July 2010 2011 2012 2013 2013 2014 2014 2015 2015 2016 2016 Request 8328, Dated 05/31/2013 (July 2013 Update of the Ambulatory Surgical Center Request 8338, Dated 06/07/2013 (July 2013 Update of the Hospital Outpatient Prospective Request 8786, Dated 05/23/2014 (July 2014 Update of the Ambulatory Surgical Center Request 8776, Dated 05/23/2014 (July 2014 Update of the Hospital Outpatient Prospective Request 9207, Dated 06/05/2015 (July 2015 Update of the Ambulatory Surgical Center Request 9205, Dated 06/05/2015 (July 2015 Update of the Hospital Outpatient Prospective Request 9658, Dated 05/13/2016 (July 2016 Update of the Hospital Outpatient Prospective Request 9668, Dated 05/27/2016 (July 2016 Update of the Ambulatory Surgical Center Update Update Update Update Update Update Update Update Update Update Update to of of of of of of of of of of the the the the the the the the the the the Ambulatory Surgical Center (ASC) Payment System Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Surgical Center (ASC) Payment System Ambulatory Surgical Center (ASC) Payment System Hospital Outpatient Prospective Payment System (OPPS) Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Surgical Center (ASC) Payment System Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Surgical Center (ASC) Payment System Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Surgical Center (ASC) Payment System Related Medicare Advantage Policy Guidelines Anterior Segment Aqueous Drainage Device Category III CPT Codes Page 22 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. Artificial Hearts and Related Devices (NCD 20.9) Capsule Endoscopy Electrical Continence Aid (NCD 230.15) Electrical Nerve Stimulators (NCD 160.7) Epidural Injection Excision of Rectal Tumor External Electrocardiographic Recording Extracorporeal Shock Wave Treatment (ESWT) Heartsbreath Test for Heart Transplant Rejection (NCD 260.10) High Dose Rate Electronic Brachytherapy High Resolution Anoscopy Implantable Automatic Defibrillators (NCD 20.4) Insertion of Posterior Spinous Process Device Low Frequency, Non-Contact, Non-Thermal Ultrasound Lumbar Artificial Disc Replacement (LADR) (NCD 150.10) Ocular Telescope Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (NCD 150.13) Percutaneous Minimally Invasive Fusion Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7) Percutaneous Ventricular Assist Device Retinal Prosthesis Single Photon Emission Computed Tomography - SPECT (NCD 220.12) Stereotactic Computer Assisted Volumetric and/or Navigational Procedures Transcatheter Aortic Valve Replacement (TAVR) (NCD 20.32) Transcatheter Mitral Valve Repair (TMVR) (NCD 20.33) Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections Vertebral Augmentation Procedure (VAP)/Percutaneous Vertebroplasty Related Medicare Advantage Coverage Summaries Artificial Disc Replacement, Cervical and Lumbar (LADR) Brachytherapy Procedures Complementary and Alternative Medicine Gastroesophageal and Gastrointestinal (GI) Services and Procedures Glaucoma Surgical Treatments Orthopedic Procedures, Devices and Products Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services Spine Procedures Transcatheter Heart Valve Procedures Uterine Services and Procedures Vision Services, Therapy and Rehabilitation UnitedHealthcare Commercial Policies Abnormal Uterine Bleeding and Uterine Fibroids Apheresis Attended Polysomnography for Evaluation of Sleep Disorders Autologous Chondrocyte Transplantation in the Knee Bariatric Surgery Bone or Soft Tissue Healing and Fusion Enhancement Products Breast Imaging for Screening and Diagnosing Cancer Bronchial Thermoplasty Cardiovascular Disease Risk Tests Corneal Hysteresis and Intraocular Pressure Measurement Electrical Stimulation and Electromagnetic Therapy for Wounds Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Epidural Steroid and Facet Injections for Spinal Pain Extracorporeal Shock Wave Therapy Fecal Calprotectin Testing Functional Endoscopic Sinus Surgery (FESS) Gastrointestinal Motility Disorders, Diagnosis and Treatment Glaucoma Surgical Treatments Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors Infertility Diagnosis and Treatment Macular Degeneration Treatment Procedures Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Category III CPT Codes Page 23 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. Neurophysiologic Testing Omnibus Codes Platelet Derived Growth Factors for Treatment of Wounds Prolotherapy for Musculoskeletal Indications Proton Beam Radiation Therapy Surgical Treatment for Spine Pain Total Artificial Disc Replacement for the Spine Total Artificial Heart Transcatheter Heart Valve Procedures Transcranial Magnetic Stimulation GUIDELINE HISTORY/REVISION INFORMATION Date 03/15/2017 Action/Description Quarterly review CPT codes 0378T and 0379T are being moved from the noncovered section to the possible provisional coverage section; a separate Medicare Advantage Policy Guideline will be developed to address these codes Administrative updates Category III CPT Codes Page 24 of 24 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/15/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc.
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