Fallon Health has completed its formal review of the 2014 CPT/HCPCS codes, and some of them will continue to require prior authorization. These codes have been added to the list of procedures that require prior authorization and are effective immediately. The final codes and determinations are listed below and in our online Provider Manual. Under the "Managing patient care" section, go to "PCP referral and plan prior authorization process."
| 64616 |
Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis) |
Y |
| 64617 |
Chemodenervation of muscle(s); larynx, unilateral, percutaneous (e.g., for spasmodic dysphonia), includes guidance by needle electromyography, when performed |
Y |
| 64642 |
Chemodenervation of one extremity; 1-4 muscle(s) |
Y |
| 64643 |
Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) |
Y |
| 64644 |
Chemodenervation of one extremity; 5 or more muscle(s) |
Y |
| 64645 |
Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure) |
Y |
| 64646 |
Chemodenervation of trunk muscle(s); 1-5 muscle(s) |
Y |
| 64647 |
Chemodenervation of trunk muscle(s); 6 or more muscle(s) |
Y |
| 66183 |
Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach |
Y |
| 81287 |
MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme), methylation analysis |
Y |
| 81504 |
Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores |
Y |
| 81507 |
Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy |
Y |
| 92524 |
Behavioral and qualitative analysis of voice and resonance |
Y |
| A9575 |
Injection, gadoterate meglumine, 0.1 ml |
Y |
| C5271 |
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area |
Y |
| C5272 |
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; each additional 25 sq. cm wound surface area, or part thereof (list separately in addition to code for primary procedure) |
Y |
| C5273 |
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
Y |
| C5274 |
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq. cm; each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) |
Y |
| C5275 |
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area |
Y |
| C5276 |
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq. cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) |
Y |
| C5277 |
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
Y |
| C5278 |
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq. cm; each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) |
Y |
| C9133 |
Factor ix (antihemophilic factor, recombinant), rixibus, per i.u. |
Y |
| C9497 |
Loxapine, inhalation powder, 10 mg |
Y |
| C9737 |
Laparoscopy, surgical, esophageal sphincter augmentation with device (eg, magnetic band) |
Y |
| D0393 |
Trtmnt simulation 3d image |
Y |
| D0394 |
Digital sub 2 or more images |
Y |
| D0395 |
Fusion 2 or more 3d images |
Y |
| D0601 |
Caries risk assess low risk |
Y |
| D0602 |
Caries risk assess mod risk |
Y |
| D0603 |
Caries risk assess high risk |
Y |
| D1999 |
Unspecified preventive procedure |
Y |
| D2921 |
Reattach tooth fragment |
Y |
| D2941 |
Int therapeutic restoration |
Y |
| D2949 |
Restorative foundation |
Y |
| D3355 |
Pulpal regeneration initial |
Y |
| D3356 |
Pulpal regeneration interim |
Y |
| D3357 |
Pulpal regeneration complete |
Y |
| D3427 |
Periradicular surgery |
Y |
| D3428 |
Bone graft peri per tooth |
Y |
| D3429 |
Bone graft peri each addl |
Y |
| D3431 |
Biological materials |
Y |
| D3432 |
Guided tissue regeneration |
Y |
| D4921 |
Gingival irrigation per quad |
Y |
| D5994 |
Peridontal medicament |
Y |
| D6011 |
Second stage implant surgery |
Y |
| D6013 |
Surgical place mini implant |
Y |
| D6052 |
Semi precision attach abut |
Y |
| D8694 |
Repair fixed retainers |
Y |
| E0766 |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
Y |
| J0151 |
Injection, adenosine for diagnostic use, 1 mg (not to be used to report any adenosine phosphate compounds, instead use a9270) |
Y |
| J0717 |
Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) |
Y |
| J1556 |
Injection, immune globulin (bivigam), 500 mg |
Y |
| J1602 |
Injection, golimumab, 1 mg, for intravenous use |
Y |
| J3060 |
Injection, taliglucerace alfa, 10 units |
Y |
| J9047 |
Injection, carfilzomib, 1 mg |
Y |
| J9262 |
Injection, omacetaxine mepesuccinate, 0.01 mg |
Y |
| J9306 |
Injection, pertuzumab, 1 mg |
Y |
| J9354 |
Injection, ado-trastuzumab emtansine, 1 mg |
Y |
| J9400 |
Injection, ziv-aflibercept, 1 mg |
Y |
| L5969 |
Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) |
Y |
| L8679 |
Implantable neurostimulator, pulse generator, any type |
Y |
| Q2028 |
Injection, sculptra, 0.5 mg |
Y |
| Q4137 |
Amnioexcel or biodexcel, per square centimeter |
Y |
| Q4138 |
Biodfence dryflex, per square centimeter |
Y |
| Q4139 |
Amniomatrix or biodmatrix, injectable, 1 cc |
Y |
| Q4140 |
Biodfence, per square centimeter |
Y |
| Q4141 |
Alloskin ac, per square centimeter |
Y |
| Q4142 |
Xcm biologic tissue matrix, per square centimeter |
Y |
| Q4143 |
Repriza, per square centimeter |
Y |
| Q4145 |
Epifix, injectable, 1 mg |
Y |
| Q4146 |
Tensix, per square centimeter |
Y |
| Q4147 |
Architect extracellular matrix, per square centimeter |
Y |
| Q4148 |
Neox 1k, per square centimeter |
Y |
| Q4149 |
Excellagen, 0.1 cc |
Y |
| S9960 |
Ambulance service, conventional air service, nonemergency transport, one way (fixed wing) |
Y |
| S9961 |
Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) |
Y |