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.
293 requirement pages across 28 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 293 pages.
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)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 without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine without contrast (72148)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)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)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)
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)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 without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine without contrast (72148)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)
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
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)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)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)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)Tocilizumab (Actemra) (J3262)Total Ankle Arthroplasty (27702)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Ustekinumab (Stelara) (J3357, J3358)Vedolizumab (Entyvio) (J3380)
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)
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)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
Fidelis Care
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)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)Knee Arthroscopy (29875, 29876, 29877, 29879)Knee Meniscectomy (29880, 29881, 29882, 29883)Lumbar Spinal Fusion (22612)Shoulder Arthroplasty Including Revision Procedures (23470, 23472, 23473, 23474)Shoulder Arthroscopy Rotator Cuff Repair (29827)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Vertebroplasty/Kyphoplasty (22510, 22511, 22512, 22513, 22514, 22515)
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
Mass General Brigham Health Plan
MassHealth
Medicare (CMS LCD/NCD)
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)Diabetic Therapeutic Shoes & Inserts (A5500, A5501, A5512, A5513)Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (63650, 63655, 63663, 63664, 63685, 63688, 63661)Lumbar Spinal Fusion (22612)MRI Brain without contrast (70551)MRI Lower Extremity Joint without contrast (73721)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)
MVP Health Care
NY State Medicaid (FFS)
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)
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)
Tufts Health Plan
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)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)CTA Chest (e.g., pulmonary embolism) (71275)Dupilumab (Dupixent) (J0517)Endovenous Ablation (Varicose Veins) (36475, 36476, 36478, 36479)Foot Surgery (28285, 28289, 28291)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 without contrast (72141)MRI Lower Extremity Joint without contrast (73721)MRI Lumbar Spine without contrast (72148)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)Spine Surgery (0098T, 0656T, 0657T)Tocilizumab (Actemra) (J3262)Total Knee Arthroplasty (27447)Total Shoulder Arthroplasty (23472)Ustekinumab (Stelara) (J3357, J3358)Vedolizumab (Entyvio) (J3380)Wireless Capsule Endoscopy (91110, 91111, 91112, 91113)