Aetna cpt codes. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Individual service codes will be assigned within contract service groupings. 20 - C72. Therabill Support Specialist. Aetna considers ultrasound corneal pachymetry medically necessary for the following indications: Anatomical narrow angles; or. , Cambridge, MA) has been investigated as a means of a 3-step treatment for repairing cartilage defects in the knee. 373S: Stress fracture Aetna Subject: Nonspecific Code List Keywords: Nonspecific Code List Created Date: 12/14/2016 11:17:08 AM Dear Provider: Effective June 1, 2020 Aetna Better Health of Pennsylvania will change the way unlisted and non-specific CPT and HCPCS codes are reviewed and paid. To meet the Department of Labor’s recent COVID-19 extension requirements, we’ll disregard the period that started on March 1, 2020 until July 10, 2023 (or one year, whichever period is shorter) in determining the timeliness of your claim, appeal or external review request under the federal guidelines. Aetna Better Health Participating Provider Prior Authorization Requirement Search Tool Participating Providers: To determine if prior authorization (PA) is required, enter up to six Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes or a CPT group and select SEARCH. Aetna considers autism spectrum disorder (ASD) evaluation and diagnosis medically necessary when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified and when the evaluation is performed by the appropriate certified/licensed health care professional. CPT code 96127: for conducting brief emotional and behavioral assessments performed with standardized instruments. Precertification applies to: You can submit a precertification by electronic data interchange (EDI), through our secure provider website or by phone, using the number on the member’s ID card. 49 Precertification of omalizumab (Xolair) is required of all Aetna participating providers and members in applicable plan designs. Codes requiring a 7th character are represented by "+": CPT codes covered if selection criteria are met: 58340 Apr 8, 2024 · Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. 0 - K20. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). 0: Malignant neoplasm of cerebral meninges: C71. Medical Necessity. ) ordered during an AWV may be applied toward the patient’s. Patient Health Questionnaire 9 item (PHQ-9) total score (reported) LOINC: 44261-6. Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met: Requirements for Breast Removal. " Other CPT codes related to the CPB: 90832 - 90838: Psychotherapy: 90839 - 90840: Psychotherapy for crisis: 90845 - 90853: Other psychotherapy: HCPCS codes covered if selection criteria are met: G0295: Electromagnetic therapy, to one or more areas: HCPCS codes not covered for indications listed in the CPB: Ketamine –no specific code We are assigning or reassigning individual service codes within contract service groups. . For precertification of omalizumab call (866) 752-7021 or fax (888) 267-3277. Health benefits and health insurance plans contain exclusions and limitations. Visit the secure website, available through www. 551 - M25. Aetna considers hCG medically necessary for members undergoing ovulation induction or assisted reproductive technology (ART). 0 - K21. Beginning July 11, 2023, standard Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. 7: Malignant neoplasm of brain stem: C72. This Clinical Policy Bulletin addresses corneal pachymetry. These changes are shown below. 9: Osteoarthritis of knee: M54. It will be your reference for Current Legal notices. , Varithena) medically necessary adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins for persons who meet medical necessity criteria for varicose vein treatment in section A above and both of the following Medical Necessity. Routine foot care includes, but is not limited to, the treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis. CPT codes covered if selection criteria are met: +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes not covered for indications listed in the CPB:: Acoustic therapy for anxiety/depression, Colonic cleansing / colon hydrotherapy, augmented soft tissue mobilization (ASTM), intravenous ascorbic acid (compounded), Spascupreel injection solution, supportive oligonucleotide technique (SOT), inhalation aromatherapy CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Information in the [brackets] below has been added for clarification purposes. 9: Osteoarthritis of hip: M25. g. Aetna considers total shoulder arthroplasty, shoulder hemiarthroplasty, reverse shoulder arthroplasty, and shoulder arthroplasty revision or replacement experimental, investigational, or unproven for all other indications. This process is also known as prior authorization or prior approval. What’s changing. aetna. For precertification of vedolizumab, call (866) 752-7021 or fax (888) 267-3277. , proton) imaging, brain (including brain stem); without contrast material, with contrast material(s), or without contrast material(s), followed by contrast material(s) and further sequences CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; Information in the [brackets] below has been added for clarification purposes. 66982, 66983, 66984. Aetna considers myringotomy and tympanostomy tube (also known as ventilation tube and grommet) insertion medically necessary for any of the following indications: Autophony due to patulous eustachian tube; or. See background section of this CPB for descriptions of the orthotics discussed in this policy. Corneal edema; or. Check our precertification lists. Healthcare Common Procedure Coding System (HCPCS) codes added to specific drug contract service groupings*. Codes requiring a 7th character are represented by "+": Varicella (chicken pox) and combination varicella and measles, mumps and rubella vaccine (MMRV): CPT codes covered if selection criteria are met: 90710 CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; CPT codes covered if selection criteria are met: 90678: Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use: 90679: Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use: Other CPT codes related to the CPB Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 61863: Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e. In addition, these stationary exercise devices are considered experimental, investigational, or unproven to prevent or reduce muscle atrophy in upper and lower extremities in individuals with hemiplegia or quadriplegia and for all other Find out if your prescription drug is covered by your 2024 Advanced Control Plan - Aetna. The medical necessity for treatment is clearly documented; and. First, normal cartilage is harvested from a joint margin during an arthroscopic biopsy procedure. Codes requiring a 7th character are represented by "+": Other CPT codes related to the CPB: 96365 - 96368: Intravenous infusion administration: 96372 CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; Other CPT codes related to the CPB: 77427 - 77470: Radiation treatment management: 81210: BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variants : 81235 Medical Necessity. 6 years ago. Follow. Unless noted, all updates become effective on March 1, 2023. CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Back Braces: Other CPT codes related to the CPB: 22548 - 22812: Arthrodesis: 22840 - 22855: Spinal instrumentation: 63001 - 63051, 63170 - 63200, 63250 - 63290: Laminectomy: HCPCS codes covered if selection criteria are met: Other CPT codes related to the CPB: 55700: Biopsy, prostate; needle or punch, single or multiple, any approach : 84152: Prostate specific antigen (PSA); complexed (direct measurement) 84153: total: 84154: free: HCPCS codes covered if selection criteria are met: G0416 : Surgical pathology, gross and microscopic examinations, for prostate needle Feb 27, 2020 · Other CPT codes related to the CPB: 33250 - 33266: Cardiac tissue ablation procedures: 33361 - 33369: Transcatheter aortic valve replacement with prosthetic valve (TAVR/TAVI) 93015 - 93024: Cardiovascular stress testing and ergonovine provocation test: 93650 - 93657: Intracardiac catheter ablation procedures CPT codes not covered for indications listed in the CPB: 91040: Esophageal balloon distension study, diagnostic, with provocation when performed: ICD-10 codes not covered for indications listed in the CPB: K20. If no improvement is documented within the initial 2 Excimer and pulsed dye laser treatment for persons with mild-to-moderate localized plaque psoriasis affecting 10 % or less of their body area who have failed to adequately respond to 3 or more months of topical treatments, including at least 3 of the following: CPT codes not covered for indications listed in the CPB: Alpha-defensin test (Synovasure) - no specific code: ICD-10 codes not covered for indications listed in the CPB: T84. Given that children with ASD may also have a level of intellectual Aetna OfficeLink UpdatesTM delivers timely information for your practice or facility, including important changes to plans and procedures, drug lists, behavioral health coverage updates, Medicare and state-specific news, and more. 559: Pain in hip: M84. com, for more information. Codes requiring a 7th character are represented by "+": CPT codes covered if selection criteria are met: 90670: Pneumococcal conjugate vaccine, 13 valent, for intramuscular use: 90671 Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 61885: Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array Other CPT codes related to the CPB: 95961 - 95962: Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures: HCPCS codes covered if selection criteria are met: G0339 CPT® codes* G2082 and G2083 include the evaluation with the administered drug. Updated. The reduction of nails, including the trimming of nails Applied behavior analysis involves the use of behavioral principles (such as positive reinforcement, or the use of rewards) to encourage the development of the desired behaviors in place of the less adaptive, self-defeating or even harmful behaviors the child may be using. This document is a quick guide for your ofice to use for behavioral health precertification with patients enrolled in Aetna health plans. Provider manual Resources, policies and procedures at your fingertips Aetna. Aetna considers color-flow Doppler echocardiography in adults medically necessary for the following indications: During excision of left atrial mass; Evaluation of angina; Evaluation of aortic diseases; Evaluation of aortocoronary bypass Aetna considers liquid or foam sclerotherapy (endovenous chemical ablation) (e. First trimester screening provides for earlier diagnosis of fetal aneuploidy. Changes to an individual provider’s compensation will depend on the presence or absence of specific service groupings within the contract. CPT and LOINC codes for depression screening. Bullous keratopathy; or. 51xA - T84. Aetna® will no longer reimburse CPT codes 99212–99215 or 99415–99417 when billed with code G2082 or G2083 on the same date of service by the same provider. Aetna considers diagnostic testing with FOBT, colonoscopy, sigmoidoscopy and/or DCBE medically necessary for evaluation of members with signs or symptoms of colorectal cancer or other gastrointestinal diseases. Additional services (lab, X-rays, etc. 9: Transient cerebral ischemic attacks and related syndromes: G46. According to the American College of Obstetricians and Gynecologists (ACOG), non-invasive first trimester screening for chromosomal abnormalities, such as DS, offers several potential advantages over second trimester screening. 2 CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met: 90651: Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule, for intramuscular use : CPT codes not covered for indications listed in the CPB: 90649 This code is billed\paid on Aetna® member for donor egg aspiration and transfer into Aetna member. 0 – G45. An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0. Aetna considers entry into a medically supervised outpatient pulmonary rehabilitation program medically necessary when all of the following criteria are met: Member has chronic pulmonary disease (including alpha-1 antitrypsin deficiency, asbestosis, asthma, emphysema, chronic airflow obstruction, chronic bronchitis, cystic Aetna considers in-office and in-hospital antepartum fetal surveillance with non-stress tests (NST), contraction stress tests (CST), biophysical profile (BPP), modified BPP, and umbilical artery and middle cerebral Doppler velocimetry medically necessary according to the American College of Obstetricians and Gynecologists (ACOG) Clinical Guideline on Antepartum Fetal Surveillance. Aetna considers pulsed dye laser treatment medically necessary for any of the following conditions: Actinic keratoses if member has failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery; or. CPT codes covered if selection Aetna considers ankle orthoses, ankle-foot orthoses (AFOs), and knee-ankle-foot orthoses (KAFOs) medically necessa ry (unless otherwise stated) dur able medical equipment (DME) according to the criteria set forth below. With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. Precertification occurs before inpatient admissions and select ambulatory procedures and services. 371A - M84. 50 – M54. 9: Low back pain: Marine therapy: CPT codes not covered for indications listed in the CPB: Marine therapy - no specific code Most Aetna plans exclude coverage of exercise equipment; please check benefit plan descriptions for details. 9: Gastro-esophageal reflux disease: K22. " Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. 59: Malignant neoplasm of cranial nerves: C79. 369S: Stress fracture, tibia and fibula: M84. You can use this document as an overview of best practices working with Aetna. 1: Tropical spastic paraplegia: G45. Access tools and training on how to implement depression screeners, find the CPT codes you need to get reimbursed and explore resources to help patients who screen positive. This Clinical Policy Bulletin addresses color-flow doppler echocardiography in adults. Increasing the use of depression screeners can make it easier to provide your patients with the support they need. " Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 90951: End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month CPT codes not covered for indications listed in the CPB: Low dye strapping/strapping of the chest –no specific code: ICD-10 codes not covered for indications listed in the CPB: M16. Codes. com 3302205-01-01 (4/24) Individual and group medical nutrition therapy 97802, 97083, 97084 ; Office or other outpatient visit or consult 99201 – 99205, 99211 – 99215 (Standalone) Aetna CPT® Code Pre-Authorization Process Recommendations. Barotitis media control; or. 31 - C79. Provider types affected. Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 37241: Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations CPT codes covered if selection criteria are met: 27486 - 27487: Revision of total knee arthroplasty, with or without allograft: 27488: Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee: CPT codes not covered for indications listed in the CPB: +0396T Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 0571T : Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; HCPCS codes covered if selection criteria are met:: A5500 - A5507, A5510 - A5514 Efective May 1, 2023. S4035 Artificial Insemination Menotropin 1 NA This code and cycle count apply only to Comprehensive level of benefit and not the ART (IVF) benefit. CPT codes not covered for indications listed in the CPB: 93880: Duplex scan of extracranial arteries; complete bilateral study: 93882: unilateral or limited study: ICD-10 codes covered if selection criteria are met: G04. 52xS: Infection and inflammatory reaction due to internal hip prosthesis : Portable Accelerometer-Based Navigation System: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Information in the [brackets] below has been added for clarification purposes. 0: Middle CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; Bone and Tendon Graft Substitutes and Adjuncts: CPT codes not covered for indications listed in the CPB: 0565T: Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation: 0566T Other CPT codes related to the CPB: 96365 - 96368: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) 96413 - 96417: Chemotherapy administration, intravenous infusion technique: HCPCS codes covered if selection criteria are met: J9298: Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg Table: CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; CPT codes covered if selection criteria are met:: 0007U: Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service CPT Codes / HCPCS Codes / ICD-10 Codes ; Code Code Description; Lutetium Lu 177 Dotatate (Lutathera): Other CPT codes related to the CPB: 79101: Radiopharmaceutical therapy, by intravenous administration: 84307: Somatostatin : HCPCS codes covered if selection criteria are met: A9513: Lutetium lu 177, dotatate, therapeutic, 1 millicurie Precertification of vedolizumab (Entyvio) is required of all Aetna participating providers and members in applicable plan designs. The two CPT® codes used to report AWV services are:*. Some Aetna insurance plans have implemented a pre-authorization process based both on units and specific CPT® codes. Facilities including acute short-term hospitals and ambulatory surgery centers. Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatment; and. Subject to applicable benefit plan terms and limitations, Aetna considers provision of skilled behavioral health services in the home medically necessary when all of the following criteria are met: The services are ordered by a physician or independently licensed behavioral health professional (BHP) (e. Other CPT codes related to the CPB: 95812 - 95830: Electroencephalography: HCPCS code covered if selection criteria are met: S8040 : Topographic brain mapping: HCPCS codes not covered for indications listed in the CPB: BrainScope One system (Ahead 300) - no specific code: ICD-10 codes covered if selection criteria are met (not all-inclusive Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 95921: Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio [not covered for Sudoscan] Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 0353U: Infectious agent detection by nucleic acid (DNA), Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique, urine, vaginal, pharyngeal, or rectal, each pathogen reported as detected or not detected CPT codes not covered for indications listed in the CPB: Self-collected / self-sampling HPV tests for screening of cervical cancer - no specific code: 0354U: Human papilloma virus (HPV), high-risk types (ie, 16, 18, 31, 33, 45, 52 and 58) qualitative mRNA expression of E6/E7 by quantitative polymerase chain reaction (qPCR) 87623 CPT codes covered if selection criteria are met: 22850: Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 22852: Removal of posterior segmental instrumentation: Other CPT codes related to the CPB: 97110 - 97546: Therapeutic procedures: ICD-10 codes covered if selection criteria are met: G89. Geriatric depression scale (GDS) total. Codes requiring a 7th character are represented by "+": CPT codes covered if selection criteria are met: 95700 Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). 11: Acute pain due to trauma: G89. , thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Information in the [brackets] below has been added for clarification purposes. Genital warts when home therapy with either podophyllotoxin or imiquimod has failed; or. , psychiatrist, psychologist, and social Aetna considers chiropractic services medically necessary when all of the following criteria are met: The member has a neuromusculoskeletal disorder; and. 9: Esophagitis: K21. 0 – M16. Modifier 25 will not override this edit. Get tools and guidelines from Aetna to help with submitting insurance claims and Table: CPT Codes / HCPCS Codes/ ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 00100 - 00102: Anesthesia for procedure on salivary glands, including biopsy or anesthesia for procedures on plastic repair of cleft lip CPT codes covered if selection criteria are met: 70551 - 70553 Magnetic resonance (e. This code corresponds to the LOINC codes below. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification. Codes requiring a 7th character are represented by "+": Diphtheria, tetanus toxoid, and whole-cell or acellular pertussis vaccines (Boostrix, Adacel): CPT codes covered if selection criteria are met: 90471 CPT codes covered if selection criteria are met: 11200: Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions [not covered for more than 15 lesions and billed with +11201] 11300 - 11313: Shaving of epidermal or dermal lesions: 11400 -11446: Excision of benign lesions: 11920 - 11922 CPT codes covered if selection criteria are met: 95933: Orbicularis oculi (blink) reflex, by electrodiagnostic testing: ICD-10 codes covered if selection criteria are met: C70. Improvement is documented within the initial 2 weeks of chiropractic care. They will be managed By Report at the time of claim submission. deductible and/or be subject to coinsurance. 18 CPT codes covered if selection criteria are met: 71555: Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) Other CPT codes related to the CPB: 75557-75564: Cardiac magnetic resonance imaging for velocity flow mapping: HCPCS codes covered if selection criteria are met: C8909 CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Information in the [brackets] below has been added for clarification purposes. Note: For purposes of this policy, only the ultrasound method of corneal pachymetry is considered. ONLY used when plan covers both the Aetna member and the egg donor in a complete donor cycle. AWV coding. Autologous chondrocyte implants (autologous chondrocyte transplant) (Carticel, Genzyme Inc. 58322 CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met: 99183: Physician attendance and supervision of hyperbaric oxygen therapy, per session: CPT codes not covered for indications listed in the CPB: Vaporous hyperoxia therapy (VHT) -no specific code: Other CPT codes related to the CPB CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; Information in the [brackets] below has been added for clarification purposes. 0: Achalasia of cardia: K22. 0 – M17. Get information about ICD-10 and the new HIPAA standards and learn what 76816, 76817 Ultrasound Pregnant Uterus, Real Time With Image Documentation, Follow-U (codes can be used interchangeable but not to exceed 2) 2 76830, 76856,76857 Ultrasound, Transvaginal (codes can be used interchangeable CPT codes covered if selection criteria are met: 99509: Home visit for assistance with activities of daily living and personal care: Other CPT codes related to the CPB: 92507 : Treatment of speech, language, voice communication, and/or auditory processing disorder; individual : 97010 - 97799 : Physical Medicine and Rehabilitation: 99500 - 99507 Other CPT codes related to the CPB: 76801: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester ( 14 weeks 0 days), transabdominal approach; single or first gestation 76802: each additional gestation (List separately in addition to code for primary procedure) 76817 Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 92133: Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve This Clinical Policy Bulletin addresses abdominoplasty, suction lipectomy, and ventral hernia repair. 361A - M84. Other CPT codes related to the CPB: 64400 - 64455, 64490 - 64505, 64517 : Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic [not covered for local anesthetic blockade of sympathetic ganglia] [not covered for bier block] 96360: Intravenous infusion, hydration; initial, 31 minutes to 1 hour + 96361 Other CPT codes related to the CPB: 19120 - 19126: Breast, excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions : 19316 - 19380: Breast, repair and/or reconstruction procedures: Other HCPCS codes related to the CPB: Table: CPT Codes / HCPCS Codes / ICD-10 Codes; Code Code Description; CPT codes covered if selection criteria are met:: 19081: Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance CPT codes not covered for indications listed in the CPB: Crenobalneotherapy -no specific code: ICD-10 codes not covered for indications listed in the CPB: M17. xw vz hf xl xq es cr qr yr eh