Reference library
Prior authorization requirements by payer and procedure
A source-cited reference for what each payer generally requires to approve a procedure: medical-necessity criteria, documentation, and how to submit. Each page links to its public source and shows when it was last verified.
970 requirement pages across 60 payers. General reference, not a coverage determination. Confirm with the payer before submitting.
See also prior authorization statistics (denial, appeal, and overturn rates) and state prior authorization laws (deadlines, gold-card, patient protections).
Showing all 970 pages.
AAA / Auto Club Insurance Association (MI)
Aetna
ACL Reconstruction (29888, 29889)Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Autologous Chondrocyte Implantation (27412, J7330, S2112)Bunionectomy (Hallux Valgus Correction) (28292, 28296, 28297, 28298, 28299, 28290, 28294)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Chiari Malformation Decompression Surgery (61343)Cochlear Device and/or Implantation (69930, L8614, L8619)CT Abdomen and Pelvis with contrast (74177)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)CTA Chest (e.g., pulmonary embolism) (71275)Custom Foot Orthotics (L3000, L3010, L3020)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Dupilumab (Dupixent) (J0517)Endovenous Ablation (Varicose Veins) (36475, 36476, 36478, 36479)Gastroplasty/Gastric Bypass (43631, 43632, 43633, 43634, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 49999)Gender Affirmation Surgery (55970, 55980, 56805, 57335, 11950, 11951, 11952, 11954, 15771, 15772, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15825, 15826, 15828, 17380, 19318, 21270, 30400, 30410, 30420, 30430, 30435, 30450, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720)Hammertoe Correction (28285, 28286)Hip Osteotomy (27146, S2115)Infliximab (Remicade & Biosimilars) (J1745, Q5103, Q5104, Q5121)Inpatient Confinements Including Hospital at HomeKnee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lower Limb Prosthetics Including Microprocessor-Controlled (L5781, L5782, L5856, L5857, L5858, L5859, L5926, L5968, L5969, L5973, L5980, L5987, L5999)Lumbar Spinal Fusion (22612)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint without contrast (73221)Orthognathic Surgery Procedures, Bone Grafts, Osteotomies and TMJ Management (21010, 21050, 21060, 21070, 21073, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21159, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21240, 21242, 21243, 21244, 21247, 21255, 21480, 21485, 21490, 21497, 29800, 29804)Osseointegrated Implant (69714, 69716, L8690, L8691, L8692, L8693)Osteochondral Allograft/Knee (27415)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Phototherapy & Photochemotherapy (PUVA) for Skin Conditions (96900, 96910, 96912, 96913)Plantar Fasciotomy (Plantar Fasciitis Surgery) (29893, 20550)Rituximab (Rituxan & Biosimilars) (J9312, Q5115, Q5119, Q5123)Sclerotherapy (Varicose Veins) (36465, 36466, 36468, 36470, 36471)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Skin Substitute Graft Application (chronic non-healing wounds) (15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Tocilizumab (Actemra) (J3262)Total Ankle Arthroplasty (27702)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Ustekinumab (Stelara) (J3357, J3358)Vedolizumab (Entyvio) (J3380)Ventricular Assist Devices (33975, 33978, 33979, 33981, 33990, 33991, 33992, 33993, 92970)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)Wireless Capsule Endoscopy (91110, 91111, 91112, 91113)
AIM (out-of-state / Federal BCBS)
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Allstate
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without and with contrast (71270)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
Anthem/Elevance Health
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Carpal Tunnel Surgery (29848, 64721)CT Abdomen and Pelvis with contrast (74177)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)CTA Chest (e.g., pulmonary embolism) (71275)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint without contrast (73221)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Auto-Owners Insurance
Blue Care Network (BCBSM HMO)
Blue Cross Blue Shield of Michigan
BlueCross BlueShield of Massachusetts
Bunionectomy (Hallux Valgus Correction) (28292, 28296, 28297, 28298, 28299, 28290, 28294)Lumbar Spinal Fusion (22612)MRI Lumbar Spine without contrast (72148)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Total Knee Arthroplasty (27447)
BlueCross BlueShield of Tennessee
Braven Health
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Carelon
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Cigna
ACL Reconstruction (29888, 29889)Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Autologous Chondrocyte Implantation (27412, J7330, S2112)Bunionectomy (Hallux Valgus Correction) (28292, 28296, 28297, 28298, 28299, 28290, 28294)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dupilumab (Dupixent) (J0517)Endovenous Ablation (Varicose Veins) (36475, 36476, 36478, 36479)Hip Osteotomy (27146, S2115)Infliximab (Remicade & Biosimilars) (J1745, Q5103, Q5104, Q5121)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Rituximab (Rituxan & Biosimilars) (J9312, Q5115, Q5119, Q5123)Sclerotherapy (Varicose Veins) (36465, 36466, 36468, 36470, 36471)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Skin Substitute Graft Application (chronic non-healing wounds) (15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278)Tocilizumab (Actemra) (J3262)Total Ankle Arthroplasty (27702)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Ustekinumab (Stelara) (J3357, J3358)Vedolizumab (Entyvio) (J3380)
Clover Health
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Coventry Workers' Comp
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)
Cure
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)
eviCore
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Cardiology - Diagnostic and Implants (33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 33270, 33274, 93306, 93307, 93308, 93319, 93350, 93351, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 0571T, 0614T, 0795T, 0796T, 0801T, 0802T, 0803T, 0823T, 0825T)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Abdomen and Pelvis without contrast (74176)CT Chest without contrast (71250)CT Head/Brain without contrast (70450)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)MRI Brain without and with contrast (70553)MRI Cervical Spine without and with contrast (72156)MRI Lumbar Spine without and with contrast (72158)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Fallon Health
Farm Bureau Insurance of Michigan
Fidelis Care
Frankenmuth Insurance
Geico (DOL after 10/1/12)
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without and with contrast (71270)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
Hanover Insurance
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
HAP (Health Alliance Plan)
Harvard Pilgrim Health Care
HCSC / BCBS TX-IL
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Healthfirst
Highmark BCBS
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Carpal Tunnel Surgery (29848, 64721)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Horizon BCBS NJ
ACL Reconstruction (29888, 29889)Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Autologous Chondrocyte Implantation (27412, J7330, S2112)Bunionectomy (Hallux Valgus Correction) (28292, 28296, 28297, 28298, 28299, 28290, 28294)Carpal Tunnel Surgery (29848, 64721)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Hammertoe Correction (28285, 28286)Hip Osteotomy (27146, S2115)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Skin Substitute Graft Application (chronic non-healing wounds) (15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278)Total Ankle Arthroplasty (27702)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Humana
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Viscosupplements (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332)
Independent Health
Liberty Mutual
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
Mass General Brigham Health Plan
MassHealth
Medicare (CMS LCD/NCD)
Ankle-Foot Orthosis (AFO) / Walking Boot (L1902, L1906, L1940, L1970, L4360, L4361, L4396, L4397)Anterior Cervical Discectomy and Fusion (22551)Arthrocentesis / Injection, Intermediate Joint or Bursa (20605)Arthrocentesis / Injection, Major Joint or Bursa (Intra-articular) (20610)Arthrocentesis / Injection, Small Joint or Bursa (20600)Carpal Tunnel Injection (20526)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Abdomen and Pelvis with contrast (74177)Custom Foot Orthotics (L3000, L3010, L3020)Diabetic Therapeutic Shoes & Inserts (A5500, A5501, A5512, A5513)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Epidural Steroid Injection (interlaminar / transforaminal) (62321, 62323, 64479, 64480, 64483, 64484)Injection, Tendon Origin / Insertion (20551)Injection, Tendon Sheath / Ligament (20550)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)MRI Brain without contrast (70551)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine without contrast (72148)Negative Pressure Wound Therapy (NPWT) (97605, 97606, E2402, A6550, A7000)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Routine Foot Care / Nail Debridement (11719, 11720, 11721, G0127)Skin Substitute Graft Application (chronic non-healing wounds) (15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278)Surgical Dressings (wound care supplies) (A6196, A6197, A6198, A6199, A6209, A6212, A6234, A6242, A6248, A6257)Therapeutic Injection, IM/SC (incl. ketorolac / Toradol) (96372, J1885)Total Knee Arthroplasty (27447)Trigger Point Injection (1 or 2 muscles) (20552)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Wound Debridement (11042, 11043, 11044, 11045, 11046, 11047, 97597, 97598)X-ray Ankle (2 views) (73600)X-ray Cervical Spine (2 or 3 views) (72040)X-ray Chest (2 views) (71046)X-ray Elbow (complete, min 3 views) (73080)X-ray Finger(s) (min 2 views) (73140)X-ray Foot (2 views) (73620)X-ray Foot (complete, min 3 views) (73630)X-ray Hand (2 views) (73120)X-ray Hip Unilateral with Pelvis (1 view) (73501)X-ray Hip Unilateral with Pelvis (2-3 views) (73502)X-ray Knee (1 or 2 views) (73560)X-ray Lumbosacral Spine (2 or 3 views) (72100)X-ray Ribs Bilateral (3 views) (71110)X-ray Shoulder (complete, min 2 views) (73030)X-ray Sternum (min 2 views) (71120)X-ray Toe(s) (min 2 views) (73660)X-ray Wrist (complete, min 3 views) (73110)
Meridian
Michigan Medicaid (MDHHS fee-for-service)
Michigan Workers' Compensation (WDCA - any carrier)
MVP Health Care
NJM
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without and with contrast (71270)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)
NY State Medicaid (FFS)
NY State Workers' Comp
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Optum
Anterior Cervical Discectomy and Fusion (22551)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Oscar Health
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Oxford Health Plans
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Plymouth Rock (High Point, Palisades, Teachers, Twin Lights)
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without and with contrast (71270)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)
Priority Health
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Progressive
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without and with contrast (71270)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
QualCare
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Sedgwick
Anterior Cervical Discectomy and Fusion (22551)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Lumbar Spinal Fusion (22612)Pain Injections - Spine (62281, 62291, 62292)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)
Selective
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)
State Farm
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
Travelers
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)
TRICARE
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
Tufts Health Plan
UMR
Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Pain Management Procedures (27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260)Shoulder Arthroscopy Rotator Cuff Repair (29827)Spinal Fusion Surgery (C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280, 20930, 20931, 20936, 20937, 20938)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
UnitedHealthcare
ACL Reconstruction (29888, 29889)Anterior Cervical Discectomy and Fusion (22551)Arthroplasty (Joint Replacement) (23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118)Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (29914, 29915, 29916, 29860, 29861, 29862, 29863)Arthroscopy (29805, 29806, 29807)Artificial Intervertebral Disc Surgery (Cervical Spine) (22856, 22858, 22861)Artificial Intervertebral Disc Surgery (Lumbar Spine) (22857, 22860, 22862, 22865)Autologous Chondrocyte Implantation (27412, J7330, S2112)Bariatric Surgery (43659, 43772, 43774, 43886, 43887, 43888)Bariatric Surgery with Obesity Diagnosis (43860, 43865)Body Lengthening (27685, 27685)Bone Growth Stimulator - Electronic Stimulation or Ultrasound (20974, 20975, 20979, E0747, E0748, E0749, E0760)Bone Marrow/Stem Cell Procedures (38204, 38205, 38211, 38230, 38232, 38243)Breast Reconstruction (Non-Mastectomy) (15771, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19364, 19367, 19368, 19369, 19370, 19371, 19396, L8600)Cancer Supportive Care - Antiemetic Drugs (J1456, J1434, J2468)Cancer Supportive Care - Colony Stimulating Factors (J0185, J0897, J1442, J1447, J1448, J1453, J1454, J1627, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5136, Q5157, Q5158, Q5159)Cancer Supportive Care - Erythropoiesis Stimulating Agents (J1449, Q5148, J0885)Cardiology - Diagnostic and Implants (33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 33270, 33274, 93306, 93307, 93308, 93319, 93350, 93351, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 0571T, 0614T, 0795T, 0796T, 0801T, 0802T, 0803T, 0823T, 0825T)Cardiovascular - Potentially Unproven Procedures (33289, 33361, 33362, 33363, 33364, 33365, 33366, 33369, C2624)Cardiovascular Interventions (33285, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 93580, 93653, 93656, E0616)Carpal Tunnel Surgery (29848, 64721)Cartilage Implants (27412, 27415, 27416)Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267)CT Abdomen and Pelvis with contrast (74177)CT Cervical Spine without contrast (72125)CT Lumbar Spine without contrast (72131)CTA Chest (e.g., pulmonary embolism) (71275)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Dupilumab (Dupixent) (J0517)Endovenous Ablation (Varicose Veins) (36475, 36476, 36478, 36479)Foot Surgery (28285, 28289, 28291)Hip Osteotomy (27146, S2115)Infliximab (Remicade & Biosimilars) (J1745, Q5103, Q5104, Q5121)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint without contrast (73221)Orthognathic Surgery (21010, 21050, 21060)Orthotics and Prosthetics (L0112, L0220, L0452)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)Pain Injections - Spine (62281, 62291, 62292)Rituximab (Rituxan & Biosimilars) (J9312, Q5115, Q5119, Q5123)Sclerotherapy (Varicose Veins) (36465, 36466, 36468, 36470, 36471)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Skin Substitute Graft Application (chronic non-healing wounds) (15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278)Spine Surgery (0098T, 0656T, 0657T)Tocilizumab (Actemra) (J3262)Total Ankle Arthroplasty (27702)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Ustekinumab (Stelara) (J3357, J3358)Vedolizumab (Entyvio) (J3380)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)Wireless Capsule Endoscopy (91110, 91111, 91112, 91113)
Univera Healthcare
USAA
CT Cervical Spine without contrast (72125)CT Chest with contrast (71260)CT Chest without contrast (71250)CT Head/Brain with contrast (70460)CT Head/Brain without and with contrast (70470)CT Head/Brain without contrast (70450)CT Lumbar Spine without contrast (72131)MRA Head without and with contrast (70546)MRA Neck without and with contrast (70549)MRI Brain with contrast (70552)MRI Brain without and with contrast (70553)MRI Brain without contrast (70551)MRI Cervical Spine with contrast (72142)MRI Cervical Spine without and with contrast (72156)MRI Cervical Spine without contrast (72141)MRI Lower Extremity Joint with contrast (73722)MRI Lower Extremity Joint without and with contrast (73723)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine with contrast (72149)MRI Lumbar Spine without and with contrast (72158)MRI Lumbar Spine without contrast (72148)MRI Pelvis with contrast (72196)MRI Pelvis without and with contrast (72197)MRI Pelvis without contrast (72195)MRI Thoracic Spine with contrast (72147)MRI Thoracic Spine without and with contrast (72157)MRI Thoracic Spine without contrast (72146)MRI Upper Extremity Joint with contrast (73222)MRI Upper Extremity Joint without and with contrast (73223)MRI Upper Extremity Joint without contrast (73221)Outpatient Physical Therapy (97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035)