Attn: PremierBlue SM Shield Network Providers Additions to List of Procedures Requiring Authorization

Transcription

1 Posted on NaviNet s Plan Central page, March 2007 Attn: PremierBlue SM Shield Network Providers Additions to List of Procedures Requiring Authorization Highmark Blue Shield will revise the list of procedures requiring authorization to include additional codes. The procedure codes on the following charts (beginning on Page 2) will be added to the authorization list, effective April 1, (Please note, the codes will not have authorization requirements and will not appear on the all-inclusive authorization list until the effective date, April 1, 2007.) Additionally, two procedure codes will be removed from the list, effective April 1, As of that date, the following two procedure codes will no longer require authorization: Pharmacologic management including prescription, use and review of medication with no more than minimal medical psychotherapy Q1003 New technology intraocular lens Category 3 as defined in federal register notice Remember, during the year, Highmark makes several adjustments to the full list of procedures requiring authorization. To view the all-inclusive and most up-to-date list, please go to the Provider Resource Center via NaviNet. The list is located under Administrative Reference Materials. The list of procedures requiring authorization applies to members enrolled in SelectBlue, DirectBlue (group only) and FreedomBlue SM (Highmark s Medicare Advantage PPO). As a reminder, use NaviNet to obtain authorization for services. Additional Services That Continue to Require Preauthorization In addition to the listing of procedures, the following items also continue to require preauthorization: all inpatient admissions investigational, experimental and cosmetic procedures home health selected injectable drugs outpatient advanced imaging procedures Reminder: Certain procedures require benefit verification prior to performing the procedure. Please use NaviNet to verify benefits before delivering services to members. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Blue Shield serves the 21 counties of central Pennsylvania and the Lehigh Valley as a full-service health plan. Blue Shield and the Shield symbol, SelectBlue and DirectBlue are registered marks and PremierBlue and FreedomBlue are service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. NaviNet is a registered trademark of NaviMedix, Inc.

2 A4558 A4559 A4600 A4601 A8000 A8001 A8002 A8003 A8004 A9279 E0676 E0936 E2373 E2374 E2375 E2376 E2377 E2381 E2382 E2383 E2384 E2385 E2386 CONDUCTIVE GEL OR PASTE, FOR USE WITH ELECTRICAL DEVICE (E.G., TENS, NMES), PER OZ. COUPLING GEL OR PASTE, FOR USE WITH ULTRASOUND DEVICE, PER OZ. SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, LITHIUM ION BATTERY FOR NON-PROSTHETIC USE, REPLACEMENT HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES SOFT INTERFACE FOR HELMET, REPLACEMENT ONLY MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE SPECIFIED CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE OTHER THAN KNEE POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI- PROPORTIONAL, COMPACT, OR SHORT THROW REMOTE JOYSTICK OR TOUCHPAD, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLY POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY TYPE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, 2

3 E2387 E2388 E2389 E2390 E2391 E2392 E2393 E2394 E2395 E2396 H0050 J0129 J1562 J1740 J2315 J7311 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, POWER WHEELCHAIR ACCESSORY, VALVE FOR PNEUMATIC TIRE TUBE, ANY TYPE, POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, ALCOHOL AND/OR DRUG SERVICES, BRIEF INTERVENTION, PER 15 MINUTES INJECTION, ABATACEPT, 10 MG INJECTION, IMMUNE GLOBULIN, SUBCUTANEOUS, 100 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, NALTREXONE, DEPOT FORM, 1 MG FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY, 301 TO 450 POUNDS POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT 3

4 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT 4

5 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY, 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS 5

6 K0884 K0885 K0886 K0890 K0891 K0898 K0899 L1001 L3806 L3808 L3915 L5993 L5994 L6611 L6624 L6639 L6703 L6704 L6706 L6707 L6708 L6709 L7007 L7008 L7009 L8690 POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, WEIGHT POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED POWER MOBILITY DEVICE, NOT D BY SADMERC OR DOES NOT MEET CRITERIA CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, FOOT ONLY, (FOR PATIENT WEIGHT GREATER THAN 300 LBS) ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, KNEE ONLY, (FOR PATIENT WEIGHT GREATER THAN 300 LBS) ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY TYPE UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOW TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS 6

7 L8691 L8695 S2344 T T 0163T 0164T 0165T 0166T 0167T 0171T 0172T AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT EXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ENLARGEMENT OF SINUS OSTIUM OPENING USING INFLATABLE DEVICE (I.E., BALLOON SINUPLASTY) DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, BARIATRIC, EACH ELECTRONIC ANALYSIS AND PROGRAMMING, REPROGRAMMING OF GASTRIC NEUROSTIMULATOR (I.E., MORBID OBESITY) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, EACH ADDITIONAL INTERSPACE REMOVAL OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH ADDITIONAL INTERSPACE REVISION OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH ADDITIONAL INTERSPACE TRANSMYOCARDIAL TRANSCATHETER CLOSURE OF VENTRICULAR SEPTAL DEFECT, WITH IMPLANT; WITHOUT CARDIOPULMONARY BYPASS TRANSMYOCARDIAL TRANSCATHETER CLOSURE OF VENTRICULAR SEPTAL DEFECT, WITH IMPLANT; WITH CARDIOPULMONARY BYPASS INSERTION OF POSTERIOR SPINOUS PROCESS DISTRACTION DEVICE (INCLUDING NECESSARY REMOVAL OF BONE OR LIGAMENT FOR INSERTION AND IMAGING GUIDANCE), LUMBAR; SINGLE LEVEL 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 FOR PRIMARY PROCEDURE) EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (E.G., ABDOMINOPLASTY), (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION), (LIST SEPARATELY IN ADDITION TO FOR PRIMARY PROCEDURE) MASTECTOMY FOR GYNECOMASTIA PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; ONE OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO FOR PRIMARY PROCEDURE) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, SINGLE INTERSPACE REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE EXCISION OF TENDON, FOREARM AND/OR WRIST, FLEXOR OR EXTENSOR, EACH 7

8 32998 ABLATION THERAPY FOR REDUCTION OR ERADICATION OF ONE OR MORE PULMONARY TUMOR(S) INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, RADIOFREQUENCY, UNILATERAL HYMENOTOMY, SIMPLE INCISION REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN ABDOMINAL APPROACH REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (E.G., FASANELLA-SERVAT TYPE) GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (E.G., CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC DEVICE TO SUPPLEMENT ORAL SPEECH NITRIC OXIDE EXPIRED GAS DETERMINATION NEUROFUNCTIONAL TESTING SELECTION AND ADMINISTRATION DURING NONINVASIVE IMAGING FUNCTIONAL BRAIN MAPPING, WITH TEST ADMINISTERED ENTIRELY BY A PHYSICIAN OR PSYCHOLOGIST, WITH REVIEW OF TEST RESULTS AND REPORT 8