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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 0395T, 19296, 19297, 19298, 77770, 77771, 77772, 77778, C9726
Actigraphy 95803
Adalimumab (Humira®) Abbott Pharmaceutical J0135
Administrative-Medical-- Air Ambulance A0430
Administrative-Medical-- Chemotherapy

96542

Administrative-Medical-- Factor for the Treatment of Hemophilia J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7196, J7197, J7198, J7199
Administrative-Medical-- Hemodialysis 90937
Administrative-Medical-- Intensive Outpatient Services Substance Abuse H0015
Administrative-Medical-- Other Home Hospice Q5010
Administrative-Medical-- Partial Hospitalization H0035
Administrative-Medical-- Peritoneal Dialysis 90945
Administrative-Medical-- Shift Care S9123
Administrative-Medical--Home Infusion S9379
Administrative-Medical--Intensive Outpatient Services Mental Health S9480
Administrative-Medical-Charged-Particle (Proton or Helium Ion) Radiotherapy 77520, 77522, 77523, 77525
Administrative-Medical-Hip Resurfacing at Alta Bates Summit Medical Center (Bundled Episode of Care) 27130
Administrative-Medical-Total Knee Replacement at Hoag Memorial Hospital, Orthopedic Institute,  or Alta Bates Summit Medical Center (Bundled Episode of Care) 27447
Administrative-Pharmacy S9560
Ado-trastuzumab emtansine (Kadcyla®)

J9354

Aflibercept (Eylea®) Regeneron Pharmaceuticals

J0178

Agalsidase beta (Fabrazyme®) Genzyme

J0180

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

J9015

alemtuzumab inj (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

Aripiprazole lauroxil Injection (Aristada®) C9470
Artificial Intervertebral Disc: Cervical Spine 0098T, 0375T, 22856, 22858, 22861, 22864
Artificial Intervertebral Disc: Lumbar Spine  0163T, 0164T, 0165T, 22857, 22862, 22865
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, S3854

Auditory Brainstem Implants

S2235

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

27412, J7330, S2112

Automated Percutaneous and Endoscopic Discectomy

62287

Axial Lumbosacral Interbody Fusion 0195T, 0196T, 0309T, 22586
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 Disease 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
Bortezomib (Velcade®) Millenium J9041
Botulinum Toxin A AbobotulinumtoxinA (Dysport®)

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, 77778
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 Applications of Positron Emission Tomography Scanning 78459, 78491, 78492
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
Clinical Trials S9988, S9990, S9991, S9992, S9994, S9996
Clofarabine (Clolar®) Genzyme, Inc.

J9027

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

J0775

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

0159T

Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure

0054T, 0055T, 20985

Continuous Passive Motion in the Home Setting E0935, E0936
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid S1030, S1031
Corticotropin, repository (H.P. Acthar® Gel); Questcor

J0800

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 0340T, 19105, 20983, 50250, 50542, 50593
dalbavancin (Dalvance™)

J0875

Dalteparin (Fragmin®) Pfizer J1645
daratumumab (Darzalex®)

C9476

Darbepoetin alfa (Aranesp®) Amgen J0881
Decitabine (Dacogen®) MGI Pharma J0894
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) 62287, 64999, 77012, S2348
Deep Brain Stimulation

61850, 61860, 61863, 61864, 61867, 61868, 61870, 61880, 61885, 61886, 61888, 64553, 64555, 64568, 64575, C1778, C1787, C1897, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689

Degarelix, Firmagon® Ferring Pharmaceuticals J9155
denosumab (Prolia™) Amgen J0897
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
Electrostimulation and Electromagnetic Therapy for Treating Wounds 97014, 97032, E0761, E0769, G0281, G0282, G0295, G0329
Elosulfase alfa (Vimizim®) J1322
elotuzumab (Empliciti®)

C9477

Endobronchial Brachytherapy 31643, 77316, 77317, 77318, 77761, 77762, 77763, 77770, 77771, 77772
Enoxaparin (Lovenox®) Aventis J1650
Epidural Steroid Injections for Back Pain 0228T, 0229T, 0230T, 0231T, 62310, 62311, 64479, 64480, 64483, 64484
Epoetin alfa (Procrit®) Ortho Biotech J0885
Epoprostenol (Flolan®) Gilead or generic manufacturers (Veletri®) Actelion Pharmaceuticals J1325
Eribulin (Halaven) Eisai J9179
Etanercept (Enbrel®) Amgen, Inc. J1438
eviCore 0274T, 20931, 62280, 72275, 95990, 95991
External Insulin Infusion Pump E0784
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 0019T, 0101T, 0102T, 0299T, 0300T, 28890
Facet Arthroplasty 0202T
Facet Joint Denervation 64620, 64633, 64634, 64635, 64636
Facet Joint Injections and Facet Joint Nerve Blocks 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495
Filgrastim, G-CSF, (Neupogen®) J1442
filgrastim-sndz (Zarxio®) Q5101
Fluocinolone Intravitreal implant (Iluvein®) J7313
Fluocinolone Intravitreal implant (Retisert®) J7311
Fondaparinux (Arixtra®), GlaxoSmithKline

J1652

Fosaprepitant (Emend®), Mfg by DSM Pharmaceuticals, Inc. for Merck & Co., Inc. J1453
Fulvestrant (Faslodex®), AstraZeneca J9395
Functional Neuromuscular Electrical Stimulation E0744, E0764, E0770
Galsulfase (Naglazyme®), Biomarine J1458
Gastric Electrical Stimulation

C1778, C1787, C1897, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689

Gastrointestinal Motility and Manometry Testing 91010, 91013, 91020, 91022, 91117, 91120, 91122
Gender Reassignment Surgery 11920, 11921, 11922, 11960, 11970, 11971, 15770, 19301, 19303, 19304, 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, C1813, C2622
Genetic Testing for Familial Alzheimer’s Disease

81406

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2) 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81479
Genetic Testing for Inherited Thrombophilia 81240, 81241, 81291
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes 81201, 81202, 81203, 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81401, 81403, 81406
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 81406, 81479
Genetic Testing of CADASIL Syndrome 81406
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer 81479, 81599
Golimumab (Simponi Aria®) J1602
Growth Hormone (GH) in Adults and Children,Somatropin Products:(Humatrope®), Eli Lilly (Nutropin®/NutropinAQ®), Genentech (Genotropin®), Pharmacia/Pfizer (Norditropin®), NovoNordisk (Saizen®), Serono (Tev-Tropin®), Teva (Omnitrope®), Sandoz J2941
High-Dose Rate Temporary Prostate Brachytherapy 77316, 77317, 77318, 77770, 77771, 77772, 77778
Histrelin implant (Supprelin LA®) Indevus J9226
Histrelin implant (Vantas™) Indevus J9225
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease

83090

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 (Hymovis) C9471
Hyaluronic acid (Monovisc®) J7327
Hyaluronic acid (Orthovisc®) J7324
Hyaluronic acid (Synvisc® , Synvisc One®) J7325
Hydroxyprogesterone caproate injection (Makena, KV Pharmaceuticals) J1725
Hyperbaric Oxygen Therapy 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 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, J1575
Implantable Bone-Conduction and Bone-Anchored Hearing Aids 69710, 69711, 69714, 69715, 69717, 69718, L8690, L8691, L8693
Implantable Cardioverter Defibrillator 33216, 33217, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 93287, 93640, 93641, C1721, C1722, C1777, C1882, C1895, C1896, G0448
Implantable Infusion Pump 62318, 62319, 62369, 62370
Implantation of Intrastromal Corneal Ring Segments 65785
Infliximab-dyyb (Inflectra®) Q5102
infliximab (Remicade®), Centocor J1745
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 51715, L8603, L8606
Intensity-Modulated Radiotherapy of the Breast and Lung 77301, 77338, 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy of the Prostate 77301, 77338, 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Abdomen and Pelvis 77301, 77338, 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid 77301, 77338, 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Central Nervous System Tumors 77301, 77338, 77385, 77386, G6015, G6016
Interferon Alfa 2b (Intron A®), Schering

J9214

Interferon Alfa-n3 (Alferon N®), Purdue J9215
Interferon gamma-1b (Actimmune®), InterMune J9216
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment 78811, 78812, 78813, 78814, 78815, 78816
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain 77761, 77762, 77763, 77770, 77771, 77772
Ipilimumab (Yervoy) Bristol-Myers Squibb J9228
Irinotecan liposome inj (Onivyde®) C9474
isavuconazonium (Cresemba®) J1833
IV Antibiotics for Tickborne Infections J0456, J0558, J0561, J0696, J0698, J1956, J2540
Ixabepilone (Ixempra®), Bristol-Myers Squibb J9207
KRAS Mutation Analysis in Non-Small-Cell Lung Cancer 81403
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer 81210, 81406
Knee Arthroplasty for Adults 27447, 27486, 27487, 27488
Knee Braces L1840, L1844, L1846
Laboratory Tests for Heart Transplant Rejection 84999
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
Lower Limb Prostheses L5100, L5105, L5150, L5160, L5200, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5617, L5700, L5701, L5702, L5930, L5990
Lumbar Spinal Fusion 22532, 22533, 22534, 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 of the Breast 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908
Magnetic Resonance Imaging to Monitor Integrity of Silicone-Gel-Filled Breast Implants 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908
Measurement of Exhaled Nasal Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders 95012
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk 83698
Mecasermin (Increlex®), Tercica J2170
Mepolizumab (Nucala®) C9473
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
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorodeoxyglucose F 18 Positron Emission Tomography 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816
Multigene Expression Assay for Predicitng Recurrence in Colon Cancer 84999
Multiple Sclerosis Drug Therapy Glatiramer (Copaxone®, Glatopa) J1595
Multiple Sclerosis Drug Therapy Interferon beta 1A (Avonex®), Biogen J1826
Multiple Sclerosis Drug Therapy Interferon beta 1B (Betaseron®), Chiron, (Extavia®), Novartis J1830
Naltrexone (Vivitrol®) Cephalon J2315
Natalizumab (Tysabri®) Biogen Idec J2323
necitumumab (Portrazza®) C9475
Negative Pressure Wound Therapy in the Outpatient Setting 97605, 97606, A6550, A9272, E2402, K0743, K0744, K0745, K0746
Neuropsychological Testing 96116, 96118, 96119, 96120
NIA Only 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 75635, 76380, 77011, 77021, 77084, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 78499, S8037
Nivolumab (Opdivo®) J9299
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA 81420, 81479, 81507, 81599, 84999
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 0111T, 81401, 82172, 82610, 82664, 83525, 83695, 83700, 83701, 83704, 85384, 85385, 86141
Obinutuzumab (Gazyva®) J9301
Occipital Nerve Stimulation 61850, 61860, 61863, 61864, 61867, 61868, 61870, 61880, 61885, 61886, 61888, 64553, 64555, 64575, 64590, C1767, C1778, C1787, C1816, C1897, L8680, L8681, L8682, L8683, L8685, L8687, L8688, L8689
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
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 Platelet-Rich Plasma 0232T
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow) 38206, 38230, 38241
Orthoptic Training for the Treatment of Vision or Learning Disabilities J92065
oritavancin (Orbactiv™) J2407
Paclitaxel protein bound suspension (Abraxane®)Abraxis oncology J9264
Pain Medication-Administration Through Pain Pumps J2278
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
Pasireotide diaspartate (Signifor®, Signifor LAR®) J2502
Pegaptanib (Macugen®); Pfizer J2503
pegfilgrastim (Neulasta®) J2505
Pegloticase (Krystexxa) Savient Pharmaceuticals J2507
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence 97014, 97032, 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 0200T, 0201T, 22510
Pertuzumab (Perjeta®) J9306
Physical Therapy 97001, 97002, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97597, 97598, 97602, 97750, 97760, 97761, 97799, G0281, G0283, G0329
Plerixafor (Mozobil®), Genzyme J2562
Positron Emission Mammography 78811, 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
Sacral Nerve Neuromodulation/Stimulation 63650, 63655, 63663, 63664, 63685, 63688, 64555, 64565, 64575, 64580, 64581, 64585, 64590, 64595, C1767, C1778, C1787, C1816, C1897, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689, L8695
Sargramostim, GM-CSF (Leukine®), Berlex J2820
Sebelipase (Kanuma®) C9478
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids 69799, S2230, V5095
Siltuximab (Sylvant) J2860
Spinal Cord Stimulation 63185, 63190, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64555, 64565, 64575, 64580, C1778, C1787, C1897, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689
Sumatriptan injection(Imitrex®) GlaxoSmithKline(Sumavel™ Dosepro™) Zogenix J3030
Surgical Deactivation of Headache Trigger Sites 15824, 15826, 30130, 30140, 30520, 64716, 67900
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea 64999
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
Talimogene Laherparepvec (Imlygic) C9472
Tbo-Filgrastim (Granix®) J1447
tedizolid (Sivextro™) J3090
Temporomandibular Joint Dysfunction 97024, 97026
Temsirolimus (Torisel®) J9330
Teriparatide (Forteo®) Eli Lilly J3110
Testosterone undecanoate (Aveed®) J3145
Tocilizumab (Actemra®) J3262
Total Hip Arthroplasty for Adults 27125, 27130, 27132, 27134, 27137, 27138, S2118
trabectedin (Yondelis®) C9480
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 IV (Remodulin®) United Therapeutics J3285
Treprostinil inhalation (Tyvaso®) United Therapeutics J7686
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 0126T
Unlisted-Pharmacy 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
Virtual Colonoscopy/Computed Tomography Colonography 74261, 74262, 74263
Wearable Cardioverter Defibrillators 93292, 93745, K0606, K0607, K0608, K0609
Whole Gland Cryoablation of Prostate Cancer 55873
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