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Prior Authorization List

The list below includes specific medical services and procedures requiring review and/or supplemental documentation prior to payment authorization. Use this list to ensure compliance with Blue Shield of California's requirements for prior authorization and improve the speed and efficiency of the claims processing.

Blue Shield of California Providers

For more information on obtaining prior authorization review refer to your provider manual. Remember to attach a copy of the prior authorization letter to claims submitted offline (i.e., paper).

Prior Authorization Requirements for Out-of-Area Blue Plan Members
View medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.

Radiology and Imaging Services

Prior authorization medical necessity reviews are recommended for certain non-emergency outpatient radiology procedures (CT, MRI, MRA, PET, cardiac nuclear medicine) for Administrative Services Only (ASO), Direct Contracting and PPO plans. Review requests for services within California are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).

Submit out of state and Point of Service (POS) authorization requests to Blue Shield for select radiological procedures. See list below.

Musculoskeletal Services

Prior authorization medical necessity reviews are recommended for certain spinal procedures (spinal surgery, spinal injections, spinal implants) for Administrative Services Only (ASO), HMO Direct Contracting, and PPO plans. Review requests for services are performed by TRIAD Healthcare, a musculoskeletal health services company. Visit triadhealthcareinc.com/bsc to use this service or call (877) 282-2510.

Federal Employee Program

Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements and generally do not require written prior authorization for the procedures and services listed below. However, for treatment requiring an inpatient stay, call (800) 633-4581 to obtain an authorization.

Out-of-Area Providers

If you are an Out-of-Area provider treating a Blue Shield of California member, refer to the Authorization List below or prior authorization requirements.

Prior Authorization List

Medical Policy Procedure Codes
Abatacept (Orencia®) Bristol-Myers Squibb J0129
Accelerated Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost With Whole-Breast Irradiation 19296, 19297, 19298, 0395T, C9726
Actigraphy 95803
Adalimumab (Humira®) Abbott Pharmaceutical J0135
Ado-trastuzumab emtansine (Kadcyla®)

J9354

Aflibercept (Eylea®) Regeneron Pharmaceuticals

J0178

Agalsidase beta (Fabrazyme®) Genzyme

J0180

Air Ambulance

A0430

Aldesleukin (Proleukin®, IL-2, Interleukin) Chiron

J9015

alemtuzumab (Lemtrada)

J0202

Alglucosidase alfa (Lumizyme®) Genzyme Corp

J0221

Alglucosidase alfa (Myozyme®) Genzyme Corp

J0220

Anidulafungin (Eraxis®) Roerig J0348
Apomorphine (Apokyn®) Mylan, Inc

J0364

Aripiprazole Injection (Abilify Maintena®)

J0401

Artificial Intervertebral Disc: Cervical Spine 22856, 22858, 22861, 22864, 0098T, 0375T
Artificial Intervertebral Disc: Lumbar Spine  22857, 22862, 22865, 0163T, 0164T, 0165T
Asparaginase Erwinia chrysanthemi (Erwinaze) EUSA Pharma

J9019

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

81519

Auditory Brainstem Implants

S2235

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

27412, J7330, S2112

Axial Lumbosacral Interbody Fusion 22586, 0195T, 0196T, 0309T
Azacitidine (VidazaTM) Pharmion

J9025

Balloon Ostial Dilation for Treatment of Chronic Sinusitis 31295, 31296, 31297
Bariatric Surgery 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
Belatacept (Nulojix®) Bristol-Myers Squibb

J0485

Belimumab (Benlysta®) GlaxoSmithKline

J0490

belinostat (Beleodaq™)

J9032

Bendamustine (Treanda®) Cephalon

J9033

Beta Amyloid Imaging with Positron Emission Tomography for Alzheimer 78811, 78814
Bevacizumab (Avastin®), Genentech

J9035

Biofeedback as a Treatment of Urinary Incontinence in Adults 90901, 90911, E0746
Blepharoplasty, Blepharoptosis Repair (levator resection) and Brow Lift (repair of brow ptosis) 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Blinatumomab (Blincyto®)

J9039

Bone Morphogenetic Protein 20930, 20931
Bortezomib (Velcade®) Millenium J9041
Botulinum Toxin A  AbobotulinumtoxinA (Dysport®) Tercica

J0586

Botulinum Toxin A IncobotulinumtoxinA (Xeomin®)

J0588

Botulinum Toxin B RimabotulinumtoxinB (Myobloc®) Solstice Neurosciences

J0587

Botulinum Toxin Type A OnobotulinumtoxinA (Botox®) Allergan

J0585

Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 77316, 77317, 77318
Breast Duct Cytology and Endoscopy

19499, 88199

Brentuximab vedotin (AdcetrisTM) Seattle Genetics

J9042

C1 Esterase Inhibitor (Berinert®; CLS Behring, Cinryze®; Lev Phar+maceuticals) J0597, J0598
C1EsteraseInhibitorRecombinant (RUCONEST) J0596
Cabazitaxel (Jevtana ®) Sanofi-Aventis

J9043

Calcitonin-Salmon (Miacalcin®) Novartis

J0630

Canakinumab (Ilaris®) Novartis

J0638

Capsaicin 8% patch (Qutenza®) NeurogesX, Inc

J7336

Cardiac Computed Tomography (CT) and Coronary CT Angiography 75571, 75572, 75573, 75574, S8092
Carfilzomib (Kyprolis®)

J9047

Caspofungin (Cancidas®) Merck J0637
Certolizumab pegol (Cimzia®) UCB

J0717

Cervical Spinal Fusion 22548, 22551, 22552, 22554, 22590, 22595, 22600
Cetuximab (Erbitux®), Bristol-Myers Squibb

J9055

Charged-Particle (Proton or Helium Ion) Radiotherapy 77520, 77522, 77523, 77525
Chemotherapy

96542

Clinical Trial S9992, S9994, S9996
Clinical Trial (Phase 1)

S9988

Clinical Trial (Phase 2)

S9990

Clinical Trial (Phase 3)

S9991

Clofarabine (Clolar®) Genzyme, Inc.

J9027

Cochlear Implant 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, L8629
Collagenase clostridium histolyticum (Xiaflex®) Auxilium Pharmaceuticals

J0775

Computed Tomography Perfusion Imaging of the Brain

0042T

Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast

0159T

Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure

0055T

Congenital Anomalies (FEP Members Only) 33813, 33814, 40700, 40701, 40702, 40720, 40761, 42200, 42225, 50070, 50135, 50405, 61680, 61682, 61684, 61686, 61690, 61692, 61710, 63250, 63251, 63252, C8921
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid S1030, S1031
Continuous Passive Motion in the Home Setting E0935, E0936
Coronary Heart Disease (CHD) - Assessment of Emerging Risk Factors 82172, 82664, 83090, 83695, 83698, 83700, 83701, 83704, 85384, 85385, 86141
Corticotropin, repository (H.P. Acthar® Gel); Questcor

J0800

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 19105, 50250, 50593
Cryosurgical Ablation of Prostate Cancer

55873

CT Abdomen 74150, 74160, 74170
CT Abdomen and Pelvis Combination 74176, 74177, 74178
CT Angiography, Abdomen

74175

CT Angiography, Abdomen and Pelvis

74174

CT Angiography, Abdominal Arteries

75635

CT Angiography, Chest (non coronary)

71275

CT Angiography, Head

70496

CT Angiography, Lower Extremity 73706
CT Angiography, Neck

70498

CT Angiography, Pelvis

72191

CT Angiography, Upper Extremity

73206

CT Cervical Spine 72125, 72126, 72127
CT Chest 71250, 71260, 71270
CT Colonography (Virtual Colonoscopy) 74261, 74262, 74263
CT Guidance 77011, 77012
CT Head/Brain 70450, 70460, 70470
CT Lower Extremity 73700, 73701, 73702
CT Lumbar Spine 72131, 72132, 72133
CT Maxillofacial/Sinus 70486, 70487, 70488
CT Orbit 70480, 70481, 70482
CT Pelvis 72192, 72193, 72194
CT Soft Tissue Neck 70490, 70491, 70492
CT Thoracic Spine 72128, 72129, 72130
CT Upper Extremity 73200, 73201, 73202
dalbavancin (Dalvance™) J0875
Dalteparin (Fragmin®) Pfizer J1645
Darbepoetin alfa (Aranesp®) Amgen J0881, J0882
Decitabine (Dacogen®) MGI Pharma J0894
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) 64999, 62287
Decompression of the Intervertebral Disc Using Laser Energy (LaserDiscectomy) or Radiofrequency Coblation (Nucleoplasty) S2348
Deep Brain Stimulation

61850, 61860, 61863, 61864, 61867, 61868, 61870, 61880, 61885, 61886, 61888, 64553, 64568

Degarelix, Firmagon® Ferring Pharmaceuticals J9155
denosumab (Xgeva) Amgendenosumab (Xgeva) Amgen J0897
Dental Anesthesia 00170
Dexamethasone intravitreal implant (Ozurdex®)

J7312

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome 95782, 95783, 95800, 95801, 95805, 95807, 95808, E0485, E0486, E0601, G0400
Diagnosis and Treatment of Sacroiliac Joint Pain 27096, G0260
Dihydroergotamine mesylate injection (D.H.E. 45®) J1110
Discectomy 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, S2350, S2351
Discography 62267, 62290, 62291, 62292, 72295
Dolasetron, Intravenous (Anzemet®) Sanofi Aventis J1260
Ecallantide (Kalbitor®) Dyax J1290
Eculizumab (Soliris®) Alexion J1300
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures E0748
Elosulfase alfa (Vimizim®) J1322
Endobronchial Brachytherapy 31643, 77761, 77762, 77763
Enoxaparin (Lovenox®) Aventis J1650
Epidural Steroid Injections for back pain 62310, 62311, 64479, 64480, 64483, 64484, 0228T, 0229T, 0230T, 0231T
Epidurography 72275
Epoetin alfa (Procrit®) Ortho Biotech J0885, Q4081
Epoprostenol (Flolan®) Gilead or generic manufacturers (Veletri®) Actelion Pharmaceuticals J1325
Eribulin (Halaven) Eisai J9179
Erythropoietin (Epogen, Procrit) J0886
Etanercept (Enbrel®) Amgen, Inc. J1438
External Insulin Infusion Pump E0784
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions 28890, 0019T, 0101T, 0102T, 0299T, 0300T
Facet Arthroplasty 0202T
Facet Joint Denervation 64620, 64633, 64634, 64635, 64636
Facet Joint Injections and Facet Joint Nerve Blocks 64490, 64491, 64492, 64493, 64494, 64495, 0214T, 0215T, 0216T, 0217T, 0218T
Factor for the Treatment of Hemophilia J7184, J7185, J7186, J7187, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, J7199
Filgrastim, G-CSF, (Neupogen®) Amgen J1442
filgrastim-sndz (Zarxio) Q5101
Fluocinolone Intravitreal implant (Iluvein®) J7313
Fluocinolone Intravitreal implant (Retisert®) J7311
Follow Up, Limited or Localized CT 76380
Fondaparinux (Arixtra®), GlaxoSmithKline J1652
Fosaprepitant (Emend®), Mfg by DSM Pharmaceuticals, Inc. for Merck & Co., Inc. J1453
Fulvestrant (Faslodex®), AstraZeneca J9395
Functional MRI Brain 70554, 70555
Functional Neuromuscular Electrical Stimulation E0744, E0764, E0770
Galsulfase (Naglazyme®), Biomarine J1458
Gastrointestinal Motility and Manometry Testing

91010, 91013, 91020, 91022, 91117, 91120, 91122, 0240T, 0241T

Gender Reassignment Surgery 11920, 11921, 11922, 11960, 11970, 11971, 15770, 19340, 19342, 31750, 53410, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55150, 55175, 55180, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 57530, 58150, 58180, 58260, 58262, 58263, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58555, 58570, 58571, 58572, 58573, 58661, 58720, 58940, 92507, C1813, C2622
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer 81479, 81599
Genetic Testing for Familial Alzheimer’s Disease 81406
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2) 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217
Genetic Testing for Inherited Thrombophilia 81240, 81241, 81291
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes 81201, 81202, 81203, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81401
Golimumab (Simponi Aria®) J1602
Growth Hormone (GH) in Adults,Somatropin Products:(Humatrope®), Eli Lilly (Nutropin®/NutropinAQ®), Genentech (Genotropin®), Pharmacia/Pfizer (Norditropin®), NovoNordisk (Saizen®), Serono (Tev-Tropin®), Teva (Omnitrope®), Sandoz J2941
Hemodialysis 90937
Hip Resurfacing at Alta Bates Summit Medical Center (Bundled Episode of Care) 27130
Histrelin implant (Supprelin LA®) Indevus J9226
Histrelin implant (Vantas™) Indevus J9225
Home Infusion S9379
Hyaluronic acid (Euflexxa® Ferring) J7323
Hyaluronic acid (Gel One®/  Seikagaku) J7326
hyaluronic acid (Gel-Syn) J7328
hyaluronic acid (Genvisc) Q9980
Hyaluronic acid (Hyalgan® Fidia/Sanofi Supartz® Seikagaku /Smith and Nephew) J7321
Hyaluronic acid (Monovisc®) J7327
Hyaluronic acid (Orthovisc®) Anika/Depuy Mitek J7324
Hyaluronic acid (Synvisc® , Synvisc One®; Genzyme) J7325
Hydroxyprogesterone caproate injection (Makena, KV Pharmaceuticals) J1725
Hyperbaric Oxygen Pressurization (HBO) 99183, A4575, E0446, G0277
Ibandronate (Boniva®), Roche J1740
Ibritumomab (Zevalin®), Cell Therapeutics, Inc (CTI), Biogen Idec A9542, A9543
icatibant (Firazyr®) Shire J1744
Idursulfase (Elaprase®) Shire J1743
Iloprost inhalation (Ventavis®), CoTherix Q4074
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis 0274T, 0275T
Imiglucerase (Cerezyme®) Genzyme J1786
Immune Globulin, Intravenous IVIG 90291, J0850, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
Immune Globulin, Subcutaneous (Hizentra® 20%), CSL Behring J1559
Implantable Bone-Conduction and Bone-Anchored Hearing Aids 69711, 69717, 69718, L8693
Implantable Cardioverter Defibrillator 33216, 33217, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 93260, 93261, 93287, 93644, C1721, C1722, C1777, C1882, C1895, C1896, G0448
Implantable Infusion Pump 62318, 62319, 62369, 62370, 95990, 95991
Implantation of Intrastromal Corneal Ring Segments 65785
infliximab (Remicade®), Centocor J1745
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 51715, L8603
Injection/infusion of neurolytic substance 62280
Intensity-Modulated Radiotherapy of the Prostate 77301, 77338, 77385, 77386, G6015, G6016
Intensive Outpatient Services Mental Health S9480
Intensive Outpatient Services Substance Abuse H0015
Interferon Alfa 2b (Intron A®), Schering J9214
Interferon Alfacon-1 (Infergen®), Three Rivers Pharmaceuticals J9212
Interferon Alfa-n3 (Alferon N®), Purdue J9215
Interferon gamma-1b (Actimmune®), InterMune J9216
Intermittent Home Health Care Visits G0154
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain 77770, 77771, 77772
Ipilimumab (Yervoy) Bristol-Myers Squibb J9228
isavuconazonium (Cresemba) J1833
IV Antibiotics for Tickborne Infections J0456, J0558, J0561, J0696, J0698, J1956, J2540
Ixabepilone (Ixempra®), Bristol-Myers Squibb J9207
Knee Braces L1840, L1844, L1846
KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer 81210
KRAS Mutation Analysis in Non-Small-Cell Lung Cancer 81403
Laminectomy 22101, 22102, 22103, 22110, 22114, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63045, 63046, 63047, 63048, 63050, 63051, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308
Lanreotide (Somatuline®); Ipsen Pharma Biotech J1930
Laronidase (Aldurazyme®) BioMarin Pharmaceutical J1931
Laser, Light Therapy, and Cryotherapy for Acne Vulgaris 17110, 17111, 17340, 96900, 96920
levoleucovorin inj (Fusilev®) Spectrum Pharmaceuticals J0641
Linezolid (Zyvox®) Pharmacia and Upjohn/Pfizer J2020
Low Dose CT For Lung Cancer Screening S8032
Lower Limb Prostheses L5100, L5105, L5150, L5160, L5200, L5230, L5250, L5270, L5280, L5301, L5311, L5312, L5321, L5331, L5341, L5617, L5700, L5701, L5702, L5930, L5990
Lumbar Spinal Fusion 22532, 22556, 22558, 22585, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22851
Lysis of Epidural Adhesions 62263, 62264, 62281, 62282
Magnetic Resonance Imaging to Monitor Integrity of Silicone-Gel-Filled Breast Implants 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908
Magnetic Resonance Spectroscopy 76390
Maternal Plasma Cell-free Fetal DNA Sequencing for Fetal Aneuploidy Detection 81507
Measurement of Exhaled Nasal Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders 95012
Mecasermin (Increlex®), Tercica J2170
methoxy polyethylene glycol-epoetin beta
(Mircera®)
J0887, J0888
methylnaltrexone (Relistor®) J2212
Micafungin (Mycamine®) Astellas Pharma J2248
Microprocessor-Controlled Prostheses for the Lower Limb L5856, L5857, L5858, L5859, L5973
MR Cholangiopancreatography S8037
MR Guidance for Needle Placement 77021
MRA Abdomen 74185
MRA Chest (excluding myocardium) 71555
MRA Head 70544, 70545, 70546
MRA Lower Extremity 73725
MRA Neck 70547, 70548, 70549
MRA Pelvis 72198
MRA Spinal Canal 72159
MRA Upper Extremity 73225
MRI Abdomen 74181, 74182, 74183
MRI Bone Marrow 77084
MRI Cervical Spine 72141, 72142, 72156
MRI Chest 71550, 71551, 71552
MRI Heart 75557, 75559, 75561, 75563, 75565
MRI Hip 73721
MRI Internal Auditory Canal 70551, 70552, 70553
MRI Lower Extremity 73718, 73719, 73720, 73722, 73723
MRI Lumbar Spine 72148, 72149, 72158
MRI Orbit, Face, and/or Neck 70540, 70542, 70543
MRI Pelvis 72195, 72196, 72197
MRI Temporomandibular Joint 70336
MRI Thoracic Spine 72146, 72147, 72157
MRI Upper Extremity Joint 73221, 73222, 73223
MRI Upper Extremity, other than Joint 73218, 73219, 73220
MUGA Scan 78472, 78473, 78494, 78496
Multigene Expression Assay for Predicitng Recurrence in Colon Cancer 84999
Multiple Sclerosis Drug Therapy Interferon beta 1A (Avonex®), Biogen J1826
Multiple Sclerosis Drug Therapy Interferon beta 1B (Betaseron®), Chiron, (Extavia®), Novartis J1830
Multiple Sclerosis Drug Therapy Glatiramer (Copaxone® ), Teva J1595
Myocardial Perfusion Imaging – Nuclear Cardiology Study 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78499
Naltrexone (Vivitrol®) Cephalon J2315
Natalizumab (Tysabri®) Biogen Idec J2323
Negative Pressure Wound Therapy in the Outpatient Setting 97605, 97606, A6550, A9272, E2402, K0743, K0744, K0745, K0746
Neuropsychological Testing 96116, 96118, 96119, 96120
Obinutuzumab (Gazyva®) J9301
Occipital Nerve Stimulation 61875, 64573, 64590, C1767, C1816
Ocriplasmin (Jetrea®) J7316
Octreotide (Sandostatin® SC/IV), Novartis J2354
Octreotide IM inj (Sandostatin LAR Depot®), Novartis J2353
Ofatumumab (Arzerra®) GlaxoSmithKline J9302
Olanzapine Long-actingInjection (Zyprexa® RelprevvTM), Eli Lilly J2358
Omacetaxine (Synribo®) J9262
Omalizumab (Xolair®) Genentech J2357
Oncologic Applications of Positron Emission Tomography Scanning 78608, 78609, 78812, 78813, 78815, 78816, G0252, S8085
Opdivo ® (nivolumab) J9299
Oprelvekin (Neumega®), Wyeth J2355
Oral/Maxillofacial Procedures (FEP Members Only) 20605, 21010, 21026, 21030, 21031, 21032, 21034, 21037, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21050, 21060, 21070, 21073, 21116, 21240, 21241, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 40490, 40500, 40510, 40520, 40525, 40527, 40530, 40650, 40800, 40801, 40804, 40805, 40806, 40808, 40810, 40812, 40814, 40816, 40819, 40820, 40830, 40831, 40840, 40842, 40843, 40844, 40845, 41000, 41005, 41006, 41007, 41008, 41009, 41010, 41015, 41016, 41017, 41018, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41115, 41116, 41120, 41130, 41150, 41250, 41251, 41252, 41520, 42000, 42100, 42104, 42106, 42107, 42120, 42140, 42160, 42300, 42305, 42310, 42320, 42330, 42335, 42340
oritavancin (Orbactiv™) J2407
Orthognathic Surgery 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21247, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996
Orthopedic Applications of Stem Cell Therapy 38206, 38230, 38241
Orthoptic Training for the Treatment of Vision or Learning Disabilities J92065
Other Home Hospice Q5010
Paclitaxel protein bound suspension (Abraxane®)Abraxis oncology J9264
Palifermin (Kepivance®); Amgen J2425
Paliperidone (Invega Sustenna®) Janssen J2426
Palivizumab (Synagis®), MedImmune 90378
Palonosetron (Aloxi®); Distributed by Eisai Inc. Licensed by Helsinn J2469
Panitumumab (Vectibix®) J9303
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis Recti 15830, 15847
Partial Hospitalization H0035
pasireotide (Signifor LAR) J2502
Pegaptanib (Macugen®); Pfizer J2503
Pegfilgrastim (Neulasta®); Amgen J2505
Pegloticase (Krystexxa) Savient Pharmaceuticals J2507
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence E0740, G0283
pembrolizumab (Keytruda®) J9271
Pemetrexed (Alimta), Eli Lilly J9305
peramivir (Rapivab™) J2547
Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation 22513, 22514, 22515
Percutaneous Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty 22526, 22527
Percutaneous Tibial Nerve Stimulation 64566, 97014, 97032
Percutaneous Vertebroplasty and Sacroplasty 22510, 22523, 22524, 22525, 0200T, 0201T
Peritoneal Dialysis 90945
Pertuzumab (Perjeta®) J9306
Plerixafor (Mozobil®), Genzyme J2562
Positron Emission Mammography (PEM) G0235
Power Wheelchairs and Power Operated Vehicles for Permanent Use E1016, E1018, E2300, E2301, E2310, E2311, E2351, E2358, E2360, E2362, E2364, E2367, E2372, E2609, E2610, E2617, K0669, K0806, K0807, K0808, K0830, K0831, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886
Pralatrexate (Folotyn®) Allos Therapeutics J9307
Prolotherapy M0076
Protein C concentrate (human) (Ceprotin®) Baxter J2724
Radioembolization for Primary and Metastatic Tumors of the Liver 37243, 75894, 77399, 77778, 79445, C2616, S2095
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 20982, 32998, 50542, 50592, 76940, 77013, 77022
Ramucirumab (Cyramza®) J9308
Ranibizumab (Lucentis®) Genentech J2778
Reduction Mammaplasty for Breast-Related Symptoms 19318
Regional Sympathetic Blocks 64520
Rilonacept (Arcalyst®)  Regeneron J2793
Risperidone Long-acting Injection (Risperdal Consta®), Janssen J2794
Rituximab (Rituxan®), Genentech J9310
Romidepsin (Istodax®) J9315
Romiplostim (Nplate™) Amgen J2796
Routine Home Hospice S9216
Sacral Nerve Neuromodulation/Stimulation 63655, 63663, 63664, 63685, 63688, 64555, 64565, 64575, 64580, 64581
Sargramostim, GM-CSF (Leukine®), Berlex J2820
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids L8691, S2230, V5095
Shift Care S9123
siltuximab (Sylvant) J2860
Spinal Cord Stimulation 63650, 63661, 63662
subcutaneous immune globulin 10% with hyaluronidase (HyQvia) J1575
Sumatriptan injection(Imitrex®) GlaxoSmithKline(Sumavel™ Dosepro™) Zogenix J3030
Surgical Deactivation of Headache Trigger Sites 15824, 15826, 30130, 30140, 30520, 64716
Surgical Treatment of Bilateral Gynecomastia 19300, 19301, 19303, 19304
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 21685, 41512, 41530, 42145, 42299
Taliglucerase alfa (Elelyso®) J3060
Tbo-Filgrastim (Granix®) J1447
tedizolid (Sivextro™) J3090
Temsirolimus (Torisel®) J9330
Teriparatide (Forteo®) Eli Lilly J3110
Testosterone undecanoate (Aveed®) J3145
Tocilizumab (Actemra®) J3262
Total Knee Replacement at Hoag Memorial Hospital/ Orthopedic Institute or Alta Bates Summit Medical Center (Bundled Episode of Care) 27447
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders 90867, 90868, 90869
Trastuzumab (Herceptin®) Genentech J9355
Treatment of Varicose Veins/Venous Insufficiency 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37765, 37766, S2202
Treprostinil inhalation (Tyvaso®) United Therapeutics J7686
Treprostinil IV (Remodulin®) United Therapeutics J3285
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 0126T
Unlisted/By Report Codes J3490, J3590, J7699, J7799, J8499, J8999, J9999
Ustekinumab (Stelara®) Centocor J3357
Vagus Nerve Stimulation C1778, C1787, C1897, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689
Vedolizumab (Entyvio®) J3380
Velaglucerase alfa (VPRIV™) Shire J3385
Vertebral Axial Decompression S9090
Vincristine liposome (Marqibo®) J9371
Wearable Cardioverter Defibrillators 93292, 93745, K0606, K0607, K0608, K0609
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon 91110, 91111
Ziconotide (Prialt®), Elan J2278
ZivAflibercept (Zaltrap®) J9400
zoledronic Acid (Reclast®, Zometa) J3489