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Prior Authorization List

The “Prior Authorization List” is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to payment authorization.

Members and providers are encouraged to obtain prior authorization and may call Customer Service to inquire about the need for prior authorization. While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering; Blue Shield may require additional information after the service is provided.

If further information is required to process the payment Blue Shield’s Claims department will reach out and will request the specific information at that time. Before providing service please contact Customer Service or access the provider connection website to verify the service is a covered benefit.

Blue Shield of California Providers

Prior authorization for the services listed below is highly recommended. For more information on obtaining prior authorization review refer to your provider manual. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.

Please include medical records when you are ready to submit for claim payment, review our medical policies, and verify the service is a covered benefit online through our provider connection website or contact Customer Service. If prior authorization was obtained and you are submitting an offline (i.e. paper) claim, remember to attach a copy of the prior authorization letter.

Prior Authorization Requirements for Out-of-Area Blue Plan Members
Please go to the “Managing Out-Of-area Blue Plan Member” section and view medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.

Advanced Imaging Services

Prior authorization medical necessity reviews are highly recommended for certain non-emergency outpatient advanced imaging procedures (CT, MRI, MRA, PET, cardiac nuclear medicine) for Administrative Services Only (ASO), HMO 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).

For out of state and Point of Service (POS) authorization requests, review the below list and submit to Blue Shield for the select advanced imaging service or procedure.

Spine Surgery and Pain Management Services

Prior authorization medical necessity reviews are highly 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 within California are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).

Federal Employee Program

Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization.

Out-of-Area Providers

If you are an Out-of-Area provider treating a Blue Shield of California member, contact the customer service phone number on the back of the member’s card to verify if the service is a covered benefit under the plan and to verify if prior authorization is required.

Prior Authorization List

Medical Policy Procedure Codes
Abatacept (Orencia) J0129
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer 19296, 19297, 19298, 77770, 77771, 77772, 77778, C9726
Actigraphy 95803
Adalimumab (Humira®) Abbott Pharmaceutical J0135
Administrative-Medical - ABA Therapy 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, 0374T, 90899, 96151, 96152, 96153, 96154, 96155, 99499, G8539, G9012, H0031, H0032, H2012, H2014, H2019, S5108, S5110, S5111
Administrative-Medical - Acute Detox (Residential Addiction Program Inpatient) H0011
Administrative-Medical - Acute Detox (Residential Addiction Program Outpatient) H0013
Administrative-Medical - Acute Detox Inpatient H0009
Administrative-Medical - Air Ambulance A0430
Administrative-Medical - Ambulatory Detox H0014
Administrative-Medical - ASC Steerage 19340, 23410, 23412, 23420, 23605, 23615, 23630, 24505, 24515, 24516, 24535, 24538, 24545, 24546, 24575, 24579, 24586, 24620, 24635, 24655, 24685, 25505, 25515, 25520, 25525, 25526, 25545, 25565, 25574, 25575, 25605, 25628, 25645, 25652, 27310, 27331, 27332, 27333, 27334, 27335, 27403, 27405, 27407, 27535, 27536, 27650, 27652, 27654, 27685, 27686, 27752, 27756, 27758, 27759, 27766, 27784, 27792, 27814, 27822, 27823, 27826, 27827, 27828, 27848, 28415, 28420, 28445, 38700, 42410, 42415, 42420, 43280, 44970, 47564, 51990, 51992, 53230, 53235, 53265, 53400, 53405, 53410, 53415, 53420, 53430, 53450, 53460, 53502, 53505, 53520, 58700, 58740, 59150, 59151, 60200, 60210, 60212, 60225, 62350, 62351, 62361, 62362, 67036, 67039, 67040, 67101, 67110
Administrative-Medical - Behavioral Health 90870, S9480
Administrative-Medical - Bone Marrow Transplant 38204, 38205, 38206, 38207, 38230, 38240, 38241, 38242, 86813, 86817
Administrative-Medical - Continuous Home Hospice T2043
Administrative-Medical - Dialysis 90935, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90993, 90999
Administrative-Medical - Factor for the Treatment of Hemophilia J7175, J7183, J7185, J7186, J7187, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7196, J7197, J7198, J7199, J7201, J7205, J7207
Administrative-Medical - Heart Lung Transplant 33935
Administrative-Medical - Heart Transplant 33945
Administrative-Medical - Hemodialysis 90937
Administrative-Medical - Home Hospice Q5010, S9126, T2042
Administrative-Medical - Home Infusion S9379
Administrative-Medical - Hospice Care (Assisted Living Facility) Q5002
Administrative-Medical - Hospice Care (Hospice Inpatient Facility) Q5006
Administrative-Medical - Hospice Care (Inpatient Hospital) Q5005
Administrative-Medical - Hospice Care (Inpatient Psych Facility) Q5008
Administrative-Medical - Hospice Care (Long-Term Care Facility) Q5007
Administrative-Medical - Hospice Care (Skilled Nursing Facility) Q5004
Administrative-Medical - Inpatient Injectable/Infusion 96413, 96415, 96416, 96417, 96440, 96446, 96450, 96542, 96549
Administrative-Medical - Intensive Outpatient Services Substance Abuse H0015, H2034
Administrative-Medical - Intestine/Bowel Transplant 44135, 44136
Administrative-Medical - Liver Transplant 47135
Administrative-Medical - Lung Transplant 32852, 32854
Administrative-Medical - Nursing/Shift Care S9123, S9124
Administrative-Medical - Outpatient Program 19301, 19303, 19304, 20670, 20680, 23130, 23415, 23625, 24360, 24361, 24362, 24363, 24370, 24371, 24565, 24577, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25447, 25535, 25606, 25607, 25608, 25609, 26992, 27176, 27178, 27250, 27252, 27265, 27266, 27330, 27409, 27457, 27530, 27532, 27550, 27552, 27556, 27557, 27558, 27606, 27705, 27769, 27780, 27781, 27840, 27842, 27846, 28292, 28296, 28297, 28298, 28299, 29826, 29827, 29830, 29834, 29835, 29836, 29837, 29838, 29840, 29843, 29844, 29845, 29846, 29847, 29855, 29856, 29860, 29861, 29862, 29863, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29882, 29883, 29884, 29885, 29886, 29887, 29891, 29892, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 32601, 32606, 32607, 32608, 32609, 32650, 32651, 32652, 32653, 32655, 32656, 32664, 32666, 32667, 32668, 33270, 33820, 33822, 33824, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37241, 37242, 37244, 38720, 38724, 39401, 39402, 41135, 42425, 42426, 43499, 44180, 44950, 45560, 49321, 49322, 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 50080, 50081, 50395, 50432, 50693, 50694, 50695, 51020, 51040, 51045, 51050, 51060, 51065, 51520, 51525, 51530, 51535, 51840, 51841, 51845, 51980, 52214, 52224, 52234, 52235, 52240, 52250, 52334, 52450, 52630, 52647, 52648, 52649, 53425, 53431, 53510, 53515, 53850, 53852, 54300, 54304, 54308, 54312, 54316, 54318, 54322, 54324, 54326, 54328, 54332, 54336, 54340, 54344, 54348, 54352, 54380, 54385, 54390, 54520, 54522, 54530, 54535, 54690, 57240, 57270, 57289, 57425, 58660, 58662, 58670, 58671, 58672, 58673, 58679, 58720, 58760, 58770, 58805, 58822, 58900, 58920, 58925, 58940, 59120, 59121, 60220, 60240, 60252, 60254, 60260, 60270, 60271, 60500, 60502, 60650, 61791, 63600, 64600, 64605, 64610, 65091, 65093, 65101, 65103, 65105, 67041, 67042, 67043, 67105, 67107, 67108, 67113, 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92986, 92987, 92990, 93640, 93641, 93655
Administrative-Medical - Pancreas Transplant 48554
Administrative-Medical - Partial Hospitalization H0035
Administrative-Medical - Peritoneal Dialysis 90945
Administrative-Medical - Solid Organ Transplant Q0508, S9975
Administrative-Medical - Subacute Detox (Residential Addiction Program Outpatient) H0012
Administrative-Medical - Subacute Detox Inpatient H0008
Administrative-Medical - Subacute Detox Inpatient (Residential Addiction Program Inpatient) H0010
Administrative-Medical - Therapeutic Behavioral Services H2020
Administrative-Pharmacy S9560
Ado-Trastuzumab Emtansine (Kadcyla®)

J9354

Aflibercept (Eylea®) Regeneron Pharmaceuticals J0178
Agalsidase Beta (Fabrazyme®) J0180
Aldesleukin (Proleukin, IL-2, Interleukin) J9015
Alemtuzumab Inj (LEMTRADA®) J0202
Alglucosidase Alfa (Lumizyme®) Genzyme Corp J0221
Anidulafungin (Eraxis) J0348
Apomorphine (Apokyn®) Mylan, Inc J0364
Aripiprazole Injection (Abilify Maintena) J0401
Aripiprazole Lauroxil Injection (Aristada®) J1942
Asparaginase Erwinia Chrysanthemi (Erwinaze) EUSA Pharma J9019
Atezolizumab (Tecentriq) J9022
Auditory Brainstem Implant S2235
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 27412, J7330, S2112
Avelumab (Bavencio) J9023
Azacitidine (Vidaza) J9025
Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis 31295, 31296, 31297, 31298
Bariatric Surgery 43632, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43886, 43887, 43888, 43999
Belatacept (Nulojix) J0485
Belimumab (Benlysta®) GlaxoSmithKline J0490
Belinostat (Beleodaq™) J9032
Bendamustine (Bendeka) J9034
Bendamustine (Treanda®) J9033
Buprenorphine extended-release injection (Sublocade) Q9991, Q9992
Beta-Amyloid Imaging With Positron Emission Tomography for Alzheimer Disease 78811, 78814
Bevacizumab (Avastin®) Genentech J9035
Bezlotoxumab (Zinplava) J0565
Biofeedback as a Treatment of Urinary Incontinence in Adults 90901, 90911, E0746
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure 33208, 33224
Blepharoplasty, Blepharoptosis Repair, (Levator Resection) and Brow Lift (Repair of Brow Ptosis) 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Blinotumomab (Blincyto®) J9039
Bortezomib (Velcade®) Millenium J9041
Botulinum Toxin A AbobotulinumtoxinA (Dysport®) J0586
Botulinum Toxin A IncobotulinumtoxinA (Xeomin®) J0588
Botulinum Toxin B RimabotulinumtoxinB (Myobloc®) J0587
Botulinum Toxin Type A OnobotulinumtoxinA (Botox®) J0585
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 77316, 77317, 77318, 77778
Breast Implant Management 19328, 19330, 19340, 19342, 19370, 19371, C1789, L8030, L8039, L8600
Brentuximab Vedotin (AdcetrisTM) J9042
Buprenorphine Implant (Probuphine) J0570
burosumab-twza (Crysvita) J0584
C1 Esterase Inhibitor (Berinert®; CLS Behring, Cinryze®; Lev Pharmaceuticals) J0597, J0598
C1 esterase inhibitor (Haegarda) J0599
C1 Esterase Inhibitor Recombinant (RUCONEST) J0596
Cabazitaxel (Jevtana ®) J9043
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
Catheter Ablation for Cardiac Arrhythmias 93650, 93653, 93654
Certolizumab Pegol (Cimzia) J0717
Cetuximab (Erbitux®) Bristol-Myers Squibb J9055
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions 77520, 77522, 77523, 77525
Clinical Trials S9988, S9990, S9991, S9992, S9994, S9996
Clofarabine (Clolar) 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
Computed Tomography to Detect Coronary Artery Calcification 75571
Computer-Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast 0159T
Continuous Passive Motion in the Home Setting E0935, E0936
copanlisib (Aliqopa) J9057
Corticotropin, Repository (H.P. Acthar® Gel) Questcor J0800
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 19105, 20983, 32994, 50250, 50542, 50593
Dalbavancin (Dalvance™) J0875
Dalteparin (Fragmin) J1645
Daratumumab (Darzalex) J9145
Darbepoetin Alfa (Aranesp®) Amgen J0881
daunorubicin cytarabine liposome (Vyxeos) J9153
decitabine (Dacogen) J0894
Degarelix (Firmagon®) Ferring Pharmaceuticals J9155
Denosumab (Prolia™) Amgen J0897
Denosumab (Xgeva) 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, 95810, 95811, E0485, E0486, E0601, G0400
Dihydroergotamine Mesylate Injection (D.H.E. 45®) J1110
Durvalumab (Imfinzi) J9173
Ecallantide (Kalbitor®) Dyax J1290
Eculizumab (Soliris®) Alexion J1300
Edaravone (Radicava) J1301
Elective Percutaneous Coronary Intervention (PCI) 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, C1874, C9600, C9601, C9602, C9603, C9604, C9605, C9607, C9608
Elosulfase Alfa (Vimizim®) J1322
Elotuzumab (Empliciti®) J9176
Endobronchial Brachytherapy 31643, 77316, 77317, 77318, 77761, 77762, 77763, 77770, 77771, 77772
enoxaparin (Lovenox) J1650
Epoetin Alfa (Procrit®) Ortho Biotech J0885
epoetin alfa-epbx (Retacrit) Q5106
Epoprostenol (Flolan®) Gilead or generic manufacturers (Veletri®) Actelion Pharmaceuticals J1325
Eribulin (Halaven) J9179
Etanercept (Enbrel®) Amgen, Inc. J1438
Eteplirsen (Exondys 51) J1428
External Insulin Infusion Pump E0784
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 0101T, 0102T, 28890
Filgrastim-aafi (Nivestym) Q5110
Filgrastim, G-CSF, (Neupogen®) J1442
Filgrastim-Sndz (Zarxio®) Q5101
Fluocinolone Intravitreal Implant (Iluvein®) J7313
Fluocinolone Intravitreal Implant (Retisert®) J7311
Fondaparinux (Arixtra®) GlaxoSmithKline J1652
Fulvestrant (Faslodex®) AstraZeneca J9395
Functional Neuromuscular Electrical Stimulation E0744, E0764, E0770
Galsulfase (Naglazyme®) Biomarine J1458
Gemtuzumab Ozogamicin (Mylotarg) J9203
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 BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers 81162, 81163, 81164, 81165, 81166, 81167, 81212, 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, 81317, 81318, 81319, 81401, 81403, 81406
Genetic Testing for Mitochondrial Disorders 81460, 81465
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 81406, 81479
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer 81479, 81599
Golimumab (Simponi Aria®) J1602
Granisetron (Sustol) J1627
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
guselkumab (Tremfya) J1628
High-Dose Rate Temporary Prostate Brachytherapy 77316, 77317, 77318, 77770, 77771, 77772, 77778
Histrelin Implant (Supprelin LA®) Indevus J9226
Histrelin Implant (Vantas™) Indevus J9225
Hyaluronic Acid (Euflexxa® Ferring) J7323
Hyaluronic Acid (Gel One®/ Seikagaku) J7326
Hyaluronic Acid (GelSyn-3®) J7328
Hyaluronic Acid (GenVisc®) J7320
Hyaluronic Acid (Hyalgan® Fidia/Sanofi Supartz® Seikagaku /Smith and Nephew) J7321
Hyaluronic Acid (Hymovis) J7322
Hyaluronic Acid (Monovisc®) J7327
Hyaluronic Acid (Orthovisc®) J7324

Hyaluronic Acid (Synvisc®, Synvisc One®)

J7325

hyaluronic acid (Trivisc)

J7329
Hydroxyprogesterone Caproate (Medicare Makena) J1726
Hydroxyprogesterone Caproate, not otherwise specified (generic for Makena) J1729
Hyperbaric Oxygen Therapy 99183, A4575, E0446, G0277
Hysterectomy Surgery for Benign Conditions 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59525
Ibalizumab-uiyk (Trogarzo) J1746
Ibandronate (Boniva®) Roche J1740
Ibritumomab (Zevalin) A9542, A9543
icatibant (Firazyr®) J1744
Idursulfase (Elaprase®) Shire J1743
Iloprost inhalation (Ventavis®) Q4074
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, C1721, C1722, C1777, C1882, C1895, C1896, G0448
Implantation of Intrastromal Corneal Ring Segments 65785
Infliximab (Remicade®), Centocor J1745
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 51715, L8603, L8606
inotuzumab ozogamicin (Besponsa) J9229
Intensity-Modulated Radiotherapy of the Breast and Lung 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy of the Prostate 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Abdomen and Pelvis 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid 77385, 77386, G6015, G6016
Intensity-Modulated Radiotherapy: Central Nervous System Tumors 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
Iobenguane I-131 (Azedra) C9407, C9408
Ipilimumab (Yervoy) Bristol-Myers Squibb J9228
Irinotecan Liposome Injection (Onivyde®) J9205
Isavuconazonium (Cresemba®) J1833
IV Antibiotics for Tickborne Infections J0456, J0558, J0561, J0696, J0698, J1956, J2540
Ixabepilone (Ixempra®) Bristol-Myers Squibb J9207
Knee Arthroscopy in Knee Osteoarthritis 29880, 29881
Knee Arthroplasty for Adults 27447
Knee Braces L1840, L1844, L1846
KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer 81210
Lanreotide (Somatuline®) Ipsen Pharma Biotech J1930
Laronidase (Aldurazyme®) BioMarin Pharmaceutical J1931
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
lutetium Lu 177 dotatate (Lutathera) A9513
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer 77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908
Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants 77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908
Magnetic Resonance Spectroscopy J76390
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders 95012
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk 83698
Mecasermin (Increlex®) Tercica J2170
Melphalan (Evomela) J9245
Mepolizumab (Nucala®) J2182
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®) J0888
Methylnaltrexone (Relistor®) J2212
Micafungin (Mycamine®) Astellas Pharma J2248
Microprocessor-Controlled Prostheses for the Lower Limb L5856, L5857, L5858, L5859, L5973
Microwave and Locoregional Laser Tumor Ablation 47370, 47380, 47382
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816
Moderate Penetrance Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk 81406
mogamulizumab-kpkc (Poteligeo) C9038
Multigene Expression Assay for Predicting Recurrence in Colon Cancer 84999
Multiple Sclerosis Drug Therapy J1830
Multiple Sclerosis Drug Therapy Glatiramer (Copaxone®, Glatopa) J1595
Multiple Sclerosis Drug Therapy Interferon beta 1A (Avonex®), Biogen J1826
Natalizumab (Tysabri®) Biogen Idec J2323
Necitumumab (Portrazza) J9295
Negative Pressure Wound Therapy in the Outpatient Setting 97605, 97606, A6550, A9272, E2402, K0743, K0744, K0745, K0746
Neuropsychological Testing 96116, 96118, 96119, 96120
NIA Pain/Spine 0095T, 0098T, 0163T, 0164T, 0165T, 0195T, 0196T, 0200T, 0201T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T, 0274T, 0275T, 22526, 22527, 22533, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899, 27096, 62263, 62264, 62287, 62320, 62321, 62322, 62323, 62380, 63001, 63005, 63012, 63015, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63047, 63050, 63051, 63056, 63057, 63075, 63076, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, G0260, M0076, S2348, S2350, S2351
NIA Radiology 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, 77012, 77013, 77021, 77022, 77084, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 78499, G0297, S8037, S8092
Nivolumab (Opdivo®) J9299
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA 81420, 81479, 81599, 84999
Nonpharmacologic Treatment of Rosacea 30117
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 82172, 82610, 82664, 83695, 83700, 83701, 83704, 85384, 85385
Nusinersen (Spinraza) J2326
Obinutuzumab (Gazyva®) J9301
Ocrelizumab (Ocrevus) J2350
Ocriplasmin (Jetrea®) J7316
Octreotide (Sandostatin® SC/IV) Novartis J2354
Octreotide IM Injection (Sandostatin LAR Depot®) Novartis J2353
Ofatumumab (Arzerra®) GlaxoSmithKline J9302
Olanzapine Long-Acting Injection (Zyprexa® RelprevvTM) Eli Lilly J2358
Olaratumab (Lartruvo) J9285
Omacetaxine (Synribo) J9262
Omalizumab (Xolair®) Genentech J2357
Oncologic Applications of Positron Emission Tomography Scanning 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0235, G0252, S8085
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 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 92065
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 Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression 29826, 29827
Pasireotide Diaspartate (Signifor®, Signifor LAR®) J2502
Patisiran (Onpattro) C9036
Pegaptanib (Macugen®) Pfizer J2503
Pegfilgrastim (Neulasta®) J2505
pegfilgrastim-jmdb (Fulphila) Q5108
Pegloticase (Krystexxa) Savient Pharmaceuticals J2507
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence E0740
Pembrolizumab (Keytruda®) J9271
Pemetrexed (Alimta), Eli Lilly J9305
Peramivir (Rapivab™) J2547
Percutaneous Tibial Nerve Stimulation 64566
Pertuzumab (Perjeta®) J9306
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) J9307
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
radium Ra 223 dichloride (Xofigo) A9606
Ramucirumab (Cyramza®) J9308
Ranibizumab (Lucentis®) Genentech J2778
Reconstructive Services 15829, 19350, 19355, 19370, 30430, 57335
Reduction Mammaplasty for Breast-Related Symptoms 19318
Reslizumab (Cinqair) J2786
Rilonacept (Arcalyst®) Regeneron J2793
Risperidone Long-acting Injection (Risperdal Consta®), Janssen J2794
Rituximab (Rituxan) J9312
Rituximab (Rituxan®), Genentech J9310
Rolapitant (Varubi) C9464
Romidepsin (Istodax®) J9315
Romiplostim (Nplate™) Amgen J2796
Sargramostim, GM-CSF (Leukine®), Berlex J2820
Sebelipase (Kanuma®) J2840
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids S2230, V5095
Siltuximab (Sylvant™) J2860
sodium hyaluronate (Durolane) J7318
Subcutaneous Immune Globulin (Cuvitru) J1555
Subtalar Arthroereisis 28725, 28735
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) J9325
Tbo-Filgrastim (Granix®) J1447
Tedizolid (Sivextro™) J3090
Temsirolimus (Torisel®) J9330
Teriparatide (Forteo®) Eli Lilly J3110
Testosterone undecanoate (Aveed®) J3145
tildrakizumab-asmn (Ilumya) J3245
Tisagenlecleucel (Kymriah) Q2042
Tocilizumab (Actemra®) J3262
Total Artificial Hearts and Implantable Ventricular Assist Devices 33927, 33928, 33929
Total Hip Arthroplasty for Adults 27130
Trabectedin (Yondelis®) J9352
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders 90867, 90868, 90869
Trastuzumab (Herceptin®) J9355
Treatment of Varicose Veins/Venous Insufficiency 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37765, 37766, S2202
Treprostinil IV (Remodulin®) United Therapeutics J3285
Treprostinil inhalation (Tyvaso®) United Therapeutics J7686
triptorelin (Triptodur) J3316
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 0126T
Unlisted-Pharmacy J3490, J3590, J7699, J7799, J8499, J8999, J9999
Ustekinumab intravenous (Stelara) J3358
Ustekinumab Subcutaneous (Stelara) J3357
Vedolizumab (Entyvio®) J3380
Velaglucerase alfa (VPRIV™) Shire J3385
Vestronidase alfa-vjbk (Mepsevii) J3397
Vincristine liposome (Marqibo®) J9371
Virtual Colonoscopy/Computed Tomography Colonography 74261, 74262, 74263
voretigene neparvovec-rzyl (Luxturna) J3398
Wearable Cardioverter Defibrillators 93292, 93745, K0606, K0607, K0608, K0609
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders 81415, 81416
Whole Gland Cryoablation of Prostate Cancer 55873
Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon 91110, 91111
Ziconotide (Prialt®), Elan J2278
ZivAflibercept (Zaltrap®) J9400