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Well Sense Prior Authorization CPT Code Look-up Tool
The Plan requires prior authorization for certain services, including ALL elective inpatient admissions and certain outpatient procedures/therapies, drugs
and devices/supplies. All procedures/therapies, drugs and supplies/devices rendered during an authorized inpatient admission are considered authorized.

Please refer to the Provider Manual Section 8: Utilization Management and Prior Authorization for information regarding prior authorization.

Please see our Prior Authorization/Notification Requirements Matrix for more details on how to work with our Behavioral Health, DME, Radiology, TO FIND A CODE OR
and Transportation contracted vendors. WORD - While holding
down the CTRL key, press
Note: the F key, type in Code, then
This is not a comprehensive list of every code available. press ENTER key
Non participating providers: most services require prior authorization.”
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0018U ONC THYR 10 MICRORNA Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQ ALG more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0019U ONC RNA TISS PREDICT Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALG more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0020U RX TEST PRSMV UR Yes Please review the Well Sense Policy for Drug Screening Testing for Drugs of
W/DEF CONF more details Abuse and/or Controlled Substances

0021U ONC PRST8 DETCJ 8 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
AUTOANTB more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0022U TRGT GEN SEQ DNA&RNA Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
23 GENE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0023U ONC AML DNA Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
DETCJ/NONDETCJ more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

Codes for Anesthesia

burn excisions or debridement
01951 ANESTH BURN LESS 4 No
PERCENT

01952 ANESTH BURN 4-9 No

PERCENT

01953 ANESTH BURN EACH 9 No

PERCENT

forearm, wrist and hand

01810 ANESTH LOWER ARM No
SURGERY

01820 ANESTH LOWER ARM No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 2 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01829 ANESTH DX WRIST No

ARTHROSCOPY

01830 ANESTH LOWER ARM No

SURGERY

01832 ANESTH WRIST No

REPLACEMENT

01840 ANESTH LWR ARM No

ARTERY SURG

01842 ANESTH LWR ARM No

EMBOLECTOMY

01844 ANESTH VASCULAR No

SHUNT SURG

01850 ANESTH LOWER ARM No

VEIN SURG

01852 ANESTH LWR ARM VEIN No

REPAIR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 3 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01860 ANESTH LOWER ARM No

CASTING

Head
00100 ANESTH SALIVARY GLAND No

00102 ANESTH REPAIR OF CLEFT No

LIP

00103 ANESTH No
BLEPHAROPLASTY

00104 ANESTH ELECTROSHOCK No

00120 ANESTH EAR SURGERY No

00124 ANESTH EAR EXAM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 4 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00126 ANESTH TYMPANOTOMY No

00140 ANESTH PROCEDURES No

ON EYE

00142 ANESTH LENS SURGERY No

00144 ANESTH CORNEAL No

TRANSPLANT

00145 ANESTH VITREORETINAL No

SURG

00147 ANESTH IRIDECTOMY No

00148 ANESTH EYE EXAM No

00160 ANESTH NOSE/SINUS No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 5 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00162 ANESTH NOSE/SINUS No

SURGERY

00164 ANESTH BIOPSY OF NOSE No

00170 ANESTH PROCEDURE ON No

MOUTH

00172 ANESTH CLEFT PALATE No

REPAIR

00174 ANESTH PHARYNGEAL No

SURGERY

00176 ANESTH PHARYNGEAL No

SURGERY

00190 ANESTH FACE/SKULL No

BONE SURG

00192 ANESTH FACIAL BONE No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 6 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00210 ANESTH CRANIAL SURG No

NOS

00211 ANESTH CRAN SURG No

HEMOTOMA

00212 ANESTH SKULL DRAINAGE No

00214 ANESTH SKULL DRAINAGE No

00215 ANESTH SKULL No

REPAIR/FRACT

00216 ANESTH HEAD VESSEL No

SURGERY

00218 ANESTH SPECIAL HEAD No

SURGERY

00220 ANESTH INTRCRN NERVE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 7 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00222 ANESTH HEAD NERVE No

SURGERY

intrathoracic
00500 ANESTH ESOPHAGEAL No
SURGERY

00520 ANESTH CHEST No

PROCEDURE

00522 ANESTH CHEST LINING No

BIOPSY

00524 ANESTH CHEST DRAINAGE No

00528 ANES MEDIASCPY & DX No

THORSCPY

00529 ANES No
MEDSCPY&THORSCPY 1
LUNG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 8 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00530 ANESTH PACEMAKER No

INSERTION

00532 ANESTH VASCULAR No

ACCESS

00534 ANESTH No
CARDIOVERTER/DEFIB

00537 ANESTH CARDIAC No

ELECTROPHYS

00539 ANESTH TRACH-BRONCH No

RECONST

00540 ANESTH CHEST SURGERY No

00541 ANESTH ONE LUNG No

VENTILATION

00542 ANESTHESIA REMOVAL No

PLEURA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 9 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00546 ANESTH LUNG CHEST No

WALL SURG

00548 ANESTH TRACHEA No

BRONCHI SURG

00550 ANESTH STERNAL No

DEBRIDEMENT

00560 ANESTH HEART SURG No

W/O PUMP

00561 ANESTH HEART SURG <1 No

YR

00562 ANESTH HRT SURG No

W/PMP AGE 1+

00563 ANESTH HEART SURG No

W/ARREST

00566 ANESTH CABG W/O PUMP No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 10 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00567 ANESTH CABG W/PUMP No

00580 ANESTH HEART/LUNG No

TRANSPLNT

knee and popliteal area

01320 ANESTH KNEE AREA No
SURGERY

01340 ANESTH KNEE AREA No

PROCEDURE

01360 ANESTH KNEE AREA No

SURGERY

01380 ANESTH KNEE JOINT No

PROCEDURE

01382 ANESTH DX KNEE No

ARTHROSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 11 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01390 ANESTH KNEE AREA No

PROCEDURE

01392 ANESTH KNEE AREA No

SURGERY

01400 ANESTH KNEE JOINT No

SURGERY

01402 ANESTH KNEE No

ARTHROPLASTY

01404 ANESTH AMPUTATION AT No

KNEE

01420 ANESTH KNEE JOINT No

CASTING

01430 ANESTH KNEE VEINS No

SURGERY

01432 ANESTH KNEE VESSEL No

SURG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 12 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01440 ANESTH KNEE ARTERIES No

SURG

01442 ANESTH KNEE ARTERY No

SURG

01444 ANESTH KNEE ARTERY No

REPAIR

lower abdomen
00800 ANESTH ABDOMINAL No
WALL SURG

00802 ANESTH FAT LAYER No

REMOVAL

00810 ANESTH LOW INTESTINE No

SCOPE

00820 ANESTH ABDOMINAL No

WALL SURG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 13 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00830 ANESTH REPAIR OF No

HERNIA

00832 ANESTH REPAIR OF No

HERNIA

00834 ANESTH HERNIA REPAIR < No

1 YR

00836 ANESTH HERNIA REPAIR No

PREEMIE

00840 ANESTH SURG LOWER No

ABDOMEN

00842 ANESTH AMNIOCENTESIS No

00844 ANESTH PELVIS SURGERY No

00846 ANESTH HYSTERECTOMY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 14 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00848 ANESTH PELVIC ORGAN No

SURG

00851 ANESTH TUBAL LIGATION No

00860 ANESTH SURGERY OF No

ABDOMEN

00862 ANESTH KIDNEY/URETER No

SURG

00864 ANESTH REMOVAL OF No

BLADDER

00865 ANESTH REMOVAL OF No

PROSTATE

00866 ANESTH REMOVAL OF No

ADRENAL

00868 ANESTH KIDNEY No

TRANSPLANT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 15 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00870 ANESTH BLADDER STONE No

SURG

00872 ANESTH KIDNEY STONE No

DESTRUCT

00873 ANESTH KIDNEY STONE No

DESTRUCT

00880 ANESTH ABDOMEN No

VESSEL SURG

00882 ANESTH MAJOR VEIN No

LIGATION

lower leg (below knee)

01462 ANESTH LOWER LEG No
PROCEDURE

01464 ANESTH ANKLE/FT No

ARTHROSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 16 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01470 ANESTH LOWER LEG No

SURGERY

01472 ANESTH ACHILLES No

TENDON SURG

01474 ANESTH LOWER LEG No

SURGERY

01480 ANESTH LOWER LEG No

BONE SURG

01482 ANESTH RADICAL LEG No

SURGERY

01484 ANESTH LOWER LEG No

REVISION

01486 ANESTH ANKLE No

REPLACEMENT

01490 ANESTH LOWER LEG No

CASTING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 17 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01500 ANESTH LEG ARTERIES No

SURG

01502 ANESTH LWR LEG No

EMBOLECTOMY

01520 ANESTH LOWER LEG VEIN No

SURG

01522 ANESTH LOWER LEG VEIN No

SURG

moderate (conscious) sedation

99143 MOD SEDAT PHYS/QHP No
<5 YRS

99144 MOD SEDAT PHYS/QHP No

5YRS/>

99145 MOD SEDAT PHYS/QHP No

EA 15 MIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 18 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99148 MOD SED DIFF No

PHYS/QHP<5 YRS

99149 MOD SED DIFF PHYS/QHP No

5/>YRS

99150 MOD SED DIFF PHYS/QHP No

ADD ON

neck
00300 ANESTH No
HEAD/NECK/PTRUNK

00320 ANESTH NECK ORGAN No

1YR/>

00322 ANESTH BIOPSY OF No

THYROID

00326 ANESTH LARYNX/TRACH No

< 1 YR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 19 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00350 ANESTH NECK VESSEL No

SURGERY

00352 ANESTH NECK VESSEL No

SURGERY

obstetric
01958 ANESTH ANTEPARTUM No
MANIPUL

01960 ANESTH VAGINAL No

DELIVERY

01961 ANESTH CS DELIVERY No

01962 ANESTH EMER No

HYSTERECTOMY

01963 ANESTH CS No
HYSTERECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 20 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01965 ANESTH INC/MISSED AB No

PROC

01966 ANESTH INDUCED AB No

PROCEDURE

01967 ANESTH/ANALG VAG No

DELIVERY

01968 ANES/ANALG CS DELIVER No

ADD-ON

01969 ANESTH/ANALG CS HYST No

ADD-ON

other procedures
01990 SUPPORT FOR ORGAN No
DONOR

01991 ANESTH NERVE No

BLOCK/INJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 21 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01992 ANESTH N BLOCK/INJ No

PRONE

01996 HOSP MANAGE CONT No

DRUG ADMIN

01999 UNLISTED ANESTH No

PROCEDURE

pelvis (except hip)

01112 ANESTH BONE No
ASPIRATE/BX

01120 ANESTH PELVIS SURGERY No

01130 ANESTH BODY CAST No

PROCEDURE

01140 ANESTH AMPUTATION AT No

PELVIS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 22 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01150 ANESTH PELVIC TUMOR No

SURGERY

01160 ANESTH PELVIS No

PROCEDURE

01170 ANESTH PELVIS SURGERY No

01173 ANESTH FX REPAIR PELVIS No

01180 ANESTH PELVIS NERVE No

REMOVAL

01190 ANESTH PELVIS NERVE No

REMOVAL

perineum
00902 ANESTH ANORECTAL No
SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 23 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00904 ANESTH PERINEAL No

SURGERY

00906 ANESTH REMOVAL OF No

VULVA

00908 ANESTH REMOVAL OF No

PROSTATE

00910 ANESTH BLADDER No

SURGERY

00912 ANESTH BLADDER No

TUMOR SURG

00914 ANESTH REMOVAL OF No

PROSTATE

00916 ANESTH BLEEDING No

CONTROL

00918 ANESTH STONE REMOVAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 24 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00920 ANESTH GENITALIA No

SURGERY

00921 ANESTH VASECTOMY No

00922 ANESTH SPERM DUCT No

SURGERY

00924 ANESTH TESTIS No

EXPLORATION

00926 ANESTH REMOVAL OF No

TESTIS

00928 ANESTH REMOVAL OF No

TESTIS

00930 ANESTH TESTIS No

SUSPENSION

00932 ANESTH AMPUTATION No

OF PENIS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 25 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00934 ANESTH PENIS NODES No

REMOVAL

00936 ANESTH PENIS NODES No

REMOVAL

00938 ANESTH INSERT PENIS No

DEVICE

00940 ANESTH VAGINAL No

PROCEDURES

00942 ANESTH SURG ON No

VAG/URETHRAL

00944 ANESTH VAGINAL No

HYSTERECTOMY

00948 ANESTH REPAIR OF No

CERVIX

00950 ANESTH VAGINAL No

ENDOSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 26 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00952 ANESTH No
HYSTEROSCOPE/GRAPH

qualifying circumstances for anesthesia

99100 SPECIAL ANESTHESIA No
SERVICE

99116 ANESTHESIA WITH No

HYPOTHERMIA

99135 SPECIAL ANESTHESIA No

PROCEDURE

99140 EMERGENCY ANESTHESIA No

radiological procedures
01916 ANESTH DX No
ARTERIOGRAPHY

01920 ANESTH CATHETERIZE No

HEART

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 27 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01922 ANESTH CAT OR MRI No

SCAN

01924 ANES THER INTERVEN No

RAD ARTRL

01925 ANES THER INTERVEN No

RAD CARD

01926 ANES TX INTERV RAD No

HRT/CRAN

01930 ANES THER INTERVEN No

RAD VEIN

01931 ANES THER INTERVEN No

RAD TIPS

01932 ANES TX INTERV RAD TH No

VEIN

01933 ANES TX INTERV RAD No

CRAN VEIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 28 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01935 ANESTH PERC IMG DX SP No

PROC

01936 ANESTH PERC IMG TX SP No

PROC

shoulder and axillary

01610 ANESTH SURGERY OF No
SHOULDER

01620 ANESTH SHOULDER No

PROCEDURE

01622 ANES DX SHOULDER No

ARTHROSCOPY

01630 ANESTH SURGERY OF No

SHOULDER

01634 ANESTH SHOULDER No

JOINT AMPUT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 29 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01636 ANESTH FOREQUARTER No

AMPUT

01638 ANESTH SHOULDER No

REPLACEMENT

01650 ANESTH SHOULDER No

ARTERY SURG

01652 ANESTH SHOULDER No

VESSEL SURG

01654 ANESTH SHOULDER No

VESSEL SURG

01656 ANESTH ARM-LEG VESSEL No

SURG

01670 ANESTH SHOULDER VEIN No

SURG

01680 ANESTH SHOULDER No

CASTING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 30 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01682 ANESTH AIRPLANE CAST No

spine and spinal cord

00600 ANESTH SPINE CORD No
SURGERY

00604 ANESTH SITTING No

PROCEDURE

00620 ANESTH SPINE CORD No

SURGERY

00625 ANES SPINE TRANTHOR No

W/O VENT

00626 ANES SPINE TRANSTHOR No

W/VENT

00630 ANESTH SPINE CORD No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 31 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00632 ANESTH REMOVAL OF No

NERVES

00635 ANESTH LUMBAR No

PUNCTURE

00640 ANESTH SPINE No

MANIPULATION

00670 ANESTH SPINE CORD No

SURGERY

thorax
00400 ANESTH SKIN No
EXT/PER/ATRUNK

00402 ANESTH SURGERY OF No

BREAST

00404 ANESTH SURGERY OF No

BREAST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 32 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00406 ANESTH SURGERY OF No

BREAST

00410 ANESTH CORRECT HEART No

RHYTHM

00450 ANESTH SURGERY OF No

SHOULDER

00454 ANESTH COLLAR BONE No

BIOPSY

00470 ANESTH REMOVAL OF RIB No

00472 ANESTH CHEST WALL No

REPAIR

00474 ANESTH SURGERY OF RIB No

upper abdomen

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 33 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00700 ANESTH ABDOMINAL No

WALL SURG

00702 ANESTH FOR LIVER No

BIOPSY

00730 ANESTH ABDOMINAL No

WALL SURG

00740 ANESTH UPPER GI No

VISUALIZE

00750 ANESTH REPAIR OF No

HERNIA

00752 ANESTH REPAIR OF No

HERNIA

00754 ANESTH REPAIR OF No

HERNIA

00756 ANESTH REPAIR OF No

HERNIA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 34 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

00770 ANESTH BLOOD VESSEL No

REPAIR

00790 ANESTH SURG UPPER No

ABDOMEN

00792 ANESTH HEMORR/EXCISE No

LIVER

00794 ANESTH PANCREAS No

REMOVAL

00796 ANESTH FOR LIVER No

TRANSPLANT

00797 ANESTH SURGERY FOR No

OBESITY

upper arm and elbow

01710 ANESTH ELBOW AREA No
SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 35 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01712 ANESTH UPPR ARM No

TENDON SURG

01714 ANESTH UPPR ARM No

TENDON SURG

01716 ANESTH BICEPS TENDON No

REPAIR

01730 ANESTH UPPR ARM No

PROCEDURE

01732 ANESTH DX ELBOW No

ARTHROSCOPY

01740 ANESTH UPPER ARM No

SURGERY

01742 ANESTH HUMERUS No

SURGERY

01744 ANESTH HUMERUS No

REPAIR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 36 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01756 ANESTH RADICAL No

HUMERUS SURG

01758 ANESTH HUMERAL No

LESION SURG

01760 ANESTH ELBOW No

REPLACEMENT

01770 ANESTH UPPR ARM No

ARTERY SURG

01772 ANESTH UPPR ARM No

EMBOLECTOMY

01780 ANESTH UPPER ARM No

VEIN SURG

01782 ANESTH UPPR ARM VEIN No

REPAIR

upper leg (except knee)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 37 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01200 ANESTH HIP JOINT No

PROCEDURE

01202 ANESTH ARTHROSCOPY No

OF HIP

01210 ANESTH HIP JOINT No

SURGERY

01212 ANESTH HIP No

DISARTICULATION

01214 ANESTH HIP No

ARTHROPLASTY

01215 ANESTH REVISE HIP No

REPAIR

01220 ANESTH PROCEDURE ON No

FEMUR

01230 ANESTH SURGERY OF No

FEMUR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 38 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

01232 ANESTH AMPUTATION No

OF FEMUR

01234 ANESTH RADICAL FEMUR No

SURG

01250 ANESTH UPPER LEG No

SURGERY

01260 ANESTH UPPER LEG No

VEINS SURG

01270 ANESTH THIGH ARTERIES No

SURG

01272 ANESTH FEMORAL No

ARTERY SURG

01274 ANESTH FEMORAL No

EMBOLECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 39 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

Codes for Medicine

acupuncture
97810 ACUPUNCT W/O STIMUL No
15 MIN

97811 ACUPUNCT W/O STIMUL No

ADDL 15M

97813 ACUPUNCT W/STIMUL 15 No

MIN

97814 ACUPUNCT W/STIMUL No

ADDL 15M

allergy and clinical immunology

95004 PERCUT ALLERGY SKIN No
TESTS

95012 EXHALED NITRIC OXIDE No

MEAS

95017 PERQ & ICUT ALLG TEST No

VENOMS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 40 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95018 PERQ&IC ALLG TEST No

DRUGS/BIOL

95024 ICUT ALLERGY TEST No

DRUG/BUG

95027 ICUT ALLERGY TITRATE- No

AIRBORN

95028 ICUT ALLERGY TEST- No

DELAYED

95044 ALLERGY PATCH TESTS No

95052 PHOTO PATCH TEST No

95056 PHOTOSENSITIVITY TESTS No

95060 EYE ALLERGY TESTS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 41 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95065 NOSE ALLERGY TEST No

95070 BRONCHIAL ALLERGY No

TESTS

95071 BRONCHIAL ALLERGY No

TESTS

95076 INGEST CHALLENGE INI No

120 MIN

95079 INGEST CHALLENGE ADDL No

60 MIN

95115 IMMUNOTHERAPY ONE No

INJECTION

95117 IMMUNOTHERAPY No
INJECTIONS

95120 IMMUNOTHERAPY ONE No

INJECTION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 42 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95125 IMMUNOTHERAPY 2/> No

INJECTIONS

95130 IMMNTX 1 STING INSECT No

95131 IMMNTX 2 STING INSECTS No

95132 IMMNTX 3 STING INSECTS No

95133 IMMNTX 4 STING INSECTS No

95134 IMMNTX 5 STING INSECTS No

95144 ANTIGEN THERAPY No

SERVICES

95145 ANTIGEN THERAPY No

SERVICES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 43 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95146 ANTIGEN THERAPY No

SERVICES

95147 ANTIGEN THERAPY No

SERVICES

95148 ANTIGEN THERAPY No

SERVICES

95149 ANTIGEN THERAPY No

SERVICES

95165 ANTIGEN THERAPY No

SERVICES

95170 ANTIGEN THERAPY No

SERVICES

95180 RAPID DESENSITIZATION No

95199 ALLERGY IMMUNOLOGY No

SERVICES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 44 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

biofeedback
90901 BIOFEEDBACK TRAIN ANY Yes Please review the Well Sense Policy for Biofeedback for Urinary Incontinence Biofeedback for Urinary
NH-
METH more details Outpatient Incontinence Outpatient ( Eff
Biofeedback/In 01/01/19)
con OP

90911 BIOFEEDBACK Yes Please review the Well Sense Policy for Biofeedback for Urinary Incontinence Biofeedback for Urinary
NH-
PERI/URO/RECTAL more details Outpatient Incontinence Outpatient ( Eff
Biofeedback/In 01/01/19)
con OP

cardiovascular
92920 PRQ CARDIAC No
ANGIOPLAST 1 ART

92921 PRQ CARDIAC ANGIO No

ADDL ART

92924 PRQ CARD No

ANGIO/ATHRECT 1 ART

92925 PRQ CARD No

ANGIO/ATHRECT ADDL

92928 PRQ CARD STENT No

W/ANGIO 1 VSL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 45 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92929 PRQ CARD STENT No

W/ANGIO ADDL

92933 PRQ CARD No

STENT/ATH/ANGIO

92934 PRQ CARD No

STENT/ATH/ANGIO

92937 PRQ REVASC BYP GRAFT No

1 VSL

92938 PRQ REVASC BYP GRAFT No

ADDL

92941 PRQ CARD REVASC MI 1 No

VSL

92943 PRQ CARD REVASC No

CHRONIC 1VSL

92944 PRQ CARD REVASC No

CHRONIC ADDL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 46 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92950 HEART/LUNG No
RESUSCITATION CPR

92953 TEMPORARY EXTERNAL No

PACING

92960 CARDIOVERSION No
ELECTRIC EXT

92961 CARDIOVERSION No
ELECTRIC INT

92970 CARDIOASSIST INTERNAL No

92971 CARDIOASSIST EXTERNAL No

92973 PRQ CORONARY MECH No

THROMBECT

92974 CATH PLACE CARDIO No

BRACHYTX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 47 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92975 DISSOLVE CLOT HEART No

VESSEL

92977 DISSOLVE CLOT HEART No

VESSEL

92978 ENDOLUMINL IVUS OCT C No

1ST

92979 ENDOLUMINL IVUS OCT C No

EA

92986 REVISION OF AORTIC No

VALVE

92987 REVISION OF MITRAL No

VALVE

92990 REVISION OF No
PULMONARY VALVE

92992 REVISION OF HEART No

CHAMBER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 48 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92993 REVISION OF HEART No

CHAMBER

92997 PUL ART BALLOON REPR No

PERCUT

92998 PUL ART BALLOON REPR No

PERCUT

93000 ELECTROCARDIOGRAM No
COMPLETE

93005 ELECTROCARDIOGRAM No
TRACING

93010 ELECTROCARDIOGRAM No
REPORT

93015 CARDIOVASCULAR No* *PA req'd if performed as elective proc in

STRESS TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93016 CARDIOVASCULAR No* *PA req'd if performed as elective proc in

STRESS TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 49 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93017 CARDIOVASCULAR No* *PA req'd if performed as elective proc in

STRESS TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93018 CARDIOVASCULAR No* *PA req'd if performed as elective proc in

STRESS TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93024 CARDIAC DRUG STRESS No

TEST

93025 MICROVOLT T-WAVE No

ASSESS

93040 RHYTHM ECG WITH No

REPORT

93041 RHYTHM ECG TRACING No

93042 RHYTHM ECG REPORT No

93050 ART PRESSURE No

WAVEFORM ANALYS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 50 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93224 ECG MONIT/REPRT UP No* *PA req'd if performed as elective proc in

TO 48 HRS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93225 ECG MONIT/REPRT UP No

TO 48 HRS

93226 ECG MONIT/REPRT UP No

TO 48 HRS

93227 ECG MONIT/REPRT UP No

TO 48 HRS

93228 REMOTE 30 DAY ECG Yes 93228 and 93229 Codes are now in the Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-
REV/REPORT Ambulatory Cardiac Event (Excluding Holter Monitors) Monitors (Excluding Holter
Experimental/I Monitors(Excluding Holter Monitors), OCA Monitors) ( Eff 01/01/19)
nvestigation 3.35. Effective 2/1/17

93229 REMOTE 30 DAY ECG No 93228 and 93229 Codes are now in the Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
TECH SUPP Ambulatory Cardiac Event (Excluding Holter Monitors) Monitors (Excluding Holter
Monitors(Excluding Holter Monitors), OCA Monitors) ( Eff 01/01/19)
3.35. Effective 2/1/17

93260 PRGRMG DEV EVAL No

IMPLTBL SYS

93261 INTERROGATE SUBQ No

DEFIB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 51 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93268 ECG RECORD/REVIEW Yes* Please review BMCHP criteria for details. Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
*Will be covered only when performed in (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event the Outpatient setting. Monitors) ( Eff 01/01/19)
Monitor

93270 REMOTE 30 DAY ECG Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
REV/REPORT more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

93271 ECG/MONITORING AND Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
ANALYSIS more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

93272 ECG/REVIEW INTERPRET Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
ONLY more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

93278 ECG/SIGNAL-AVERAGED No

93279 PM DEVICE PROGR EVAL No

SNGL

93280 PM DEVICE PROGR EVAL No

DUAL

93281 PM DEVICE PROGR EVAL No

MULTI

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 52 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93282 PRGRMG EVAL No

IMPLANTABLE DFB

93283 PRGRMG EVAL No

IMPLANTABLE DFB

93284 PRGRMG EVAL No

IMPLANTABLE DFB

93285 ILR DEVICE EVAL PROGR No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93286 PERI-PX PACEMAKER No

DEVICE EVL

93287 PERI-PX DEVICE EVAL & No

PRGR

93288 PM DEVICE EVAL IN No

PERSON

93289 INTERROG DEVICE EVAL No

HEART

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 53 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93290 ICM DEVICE EVAL No

93291 ILR DEVICE INTERROGATE No

93292 WCD DEVICE No

INTERROGATE

93293 PM PHONE R-STRIP No

DEVICE EVAL

93294 PM DEVICE No
INTERROGATE REMOTE

93295 DEV INTERROG REMOTE No

1/2/MLT

93296 PM/ICD REMOTE TECH No

SERV

93297 ICM DEVICE INTERROGAT No

REMOTE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 54 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93298 ILR DEVICE INTERROGAT No

REMOTE

93299 ICM/ILR REMOTE TECH No

SERV

93303 ECHO TRANSTHORACIC No

93304 ECHO TRANSTHORACIC No

93306 TTE W/DOPPLER No

COMPLETE

93307 TTE W/O DOPPLER No

COMPLETE

93308 TTE F-UP OR LMTD No

93312 ECHO TRANSESOPHAGEAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 55 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93313 ECHO TRANSESOPHAGEAL No

93314 ECHO TRANSESOPHAGEAL No

93315 ECHO TRANSESOPHAGEAL No

93316 ECHO TRANSESOPHAGEAL No

93317 ECHO TRANSESOPHAGEAL No

93318 ECHO No
TRANSESOPHAGEAL
INTRAOP

93320 DOPPLER ECHO EXAM No

HEART

93321 DOPPLER ECHO EXAM No

HEART

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 56 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93325 DOPPLER COLOR FLOW No

ADD-ON

93350 STRESS TTE ONLY No

93351 STRESS TTE COMPLETE No

93352 ADMIN ECG CONTRAST No

AGENT

93355 ECHO No
TRANSESOPHAGEAL (TEE)

93451 RIGHT HEART CATH No

93452 LEFT HRT CATH No* *PA req'd if performed as elective proc in
W/VENTRCLGRPHY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93453 R&L HRT CATH No

W/VENTRICLGRPHY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 57 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93454 CORONARY ARTERY No* *PA req'd if performed as elective proc in

ANGIO S&I the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93455 CORONARY ART/GRFT No* *PA req'd if performed as elective proc in

ANGIO S&I the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93456 R HRT CORONARY No* *PA req'd if performed as elective proc in

ARTERY ANGIO the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93457 R HRT ART/GRFT ANGIO No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93458 L HRT No* *PA req'd if performed as elective proc in

ARTERY/VENTRICLE the Inpatient setting; incl all clinical
ANGIO documentation that supports the need for
inpatient level of care.

93459 L HRT ART/GRFT ANGIO No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93460 R&L HRT ART/VENTRICLE No

ANGIO

93461 R&L HRT ART/VENTRICLE No

ANGIO

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 58 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93462 L HRT CATH TRNSPTL No

PUNCTURE

93463 DRUG ADMIN & No

HEMODYNMIC MEAS

93464 EXERCISE No
W/HEMODYNAMIC MEAS

93503 INSERT/PLACE HEART No

CATHETER

93505 BIOPSY OF HEART LINING No

93530 RT HEART CATH No

CONGENITAL

93531 R & L HEART CATH No

CONGENITAL

93532 R & L HEART CATH No

CONGENITAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 59 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93533 R & L HEART CATH No

CONGENITAL

93561 CARDIAC OUTPUT No

MEASUREMENT

93562 CARD OUTPUT MEASURE No

SUBSQ

93563 INJECT CONGENITAL No

CARD CATH

93564 INJECT HRT CONGNTL No

ART/GRFT

93565 INJECT L VENTR/ATRIAL No

ANGIO

93566 INJECT R VENTR/ATRIAL No

ANGIO

93567 INJECT SUPRVLV No

AORTOGRAPHY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 60 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93568 INJECT PULM ART HRT No

CATH

93571 HEART FLOW RESERVE No

MEASURE

93572 HEART FLOW RESERVE No

MEASURE

93580 TRANSCATH CLOSURE OF No

ASD

93581 TRANSCATH CLOSURE OF No

VSD

93582 PERQ TRANSCATH No

CLOSURE PDA

93583 PERQ TRANSCATH No

SEPTAL REDUXN

93600 BUNDLE OF HIS No* *PA req'd if performed as elective proc in

RECORDING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 61 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93602 INTRA-ATRIAL No* *PA req'd if performed as elective proc in

RECORDING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93603 RIGHT VENTRICULAR No* *PA req'd if performed as elective proc in

RECORDING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93609 MAP TACHYCARDIA ADD- No* *PA req'd if performed as elective proc in
ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93610 INTRA-ATRIAL PACING No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93612 INTRAVENTRICULAR No* *PA req'd if performed as elective proc in

PACING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93613 ELECTROPHYS MAP 3D No* *PA req'd if performed as elective proc in

ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93615 ESOPHAGEAL RECORDING No

93616 ESOPHAGEAL RECORDING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 62 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93618 HEART RHYTHM PACING No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93619 ELECTROPHYSIOLOGY No* *PA req'd if performed as elective proc in

EVALUATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93620 ELECTROPHYSIOLOGY No* *PA req'd if performed as elective proc in

EVALUATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93621 ELECTROPHYSIOLOGY No* *PA req'd if performed as elective proc in

EVALUATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93622 ELECTROPHYSIOLOGY No* *PA req'd if performed as elective proc in

EVALUATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93623 STIMULATION PACING No* *PA req'd if performed as elective proc in

HEART the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93624 ELECTROPHYSIOLOGIC No* *PA req'd if performed as elective proc in

STUDY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93631 HEART PACING MAPPING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 63 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93640 EVALUATION HEART No

DEVICE

93641 ELECTROPHYSIOLOGY No
EVALUATION

93642 ELECTROPHYSIOLOGY No
EVALUATION

93644 ELECTROPHYSIOLOGY No
EVALUATION

93650 ABLATE HEART No* *PA req'd if performed as elective proc in

DYSRHYTHM FOCUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93653 EP & ABLATE SUPRAVENT No* *PA req'd if performed as elective proc in
ARRHYT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93654 EP & ABLATE VENTRIC No* *PA req'd if performed as elective proc in
TACHY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93655 ABLATE ARRHYTHMIA No* *PA req'd if performed as elective proc in

ADD ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 64 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93656 TX ATRIAL FIB PULM VEIN No* *PA req'd if performed as elective proc in
ISOL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93657 TX L/R ATRIAL FIB ADDL No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

93660 TILT TABLE EVALUATION No

93662 INTRACARDIAC ECG (ICE) No

93668 PERIPHERAL VASCULAR No

REHAB

93701 BIOIMPEDANCE CV No
ANALYSIS

93702 BIS XTRACELL FLUID No

ANALYSIS

93724 ANALYZE PACEMAKER No

SYSTEM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 65 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93740 TEMPERATURE No
GRADIENT STUDIES

93745 SET-UP CARDIOVERT- No

DEFIBRILL

93750 INTERROGATION VAD IN No

PERSON

93770 MEASURE VENOUS No

PRESSURE

93784 AMBULATORY BP No
MONITORING

93786 AMBULATORY BP No
RECORDING

93788 AMBULATORY BP No
ANALYSIS

93790 REVIEW/REPORT BP No
RECORDING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 66 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93797 CARDIAC REHAB Yes Please review the Well Sense Policy for Cardiac Rehabilitation, Outpatient Cardiac Rehabilitation, Cardiac Rehabilitation
IQ-Cardiac
more details Outpatient ( Eff 03/01/18 and OP used in Conjunction
Rehabilitation Retired 02/28/19) with Interqual Criteria
OP
(Effective 03/01/19)

93798 CARDIAC Yes Please review the Well Sense Policy for Cardiac Rehabilitation, Outpatient Cardiac Rehabilitation, Cardiac Rehabilitation
IQ-Cardiac
REHAB/MONITOR more details Outpatient ( Eff 03/01/18 and OP used in Conjunction
Rehabilitation Retired 02/28/19) with Interqual Criteria
OP
(Effective 03/01/19)

93799 CARDIOVASCULAR No
PROCEDURE

central nervous system assessments/tests (neuro-cognitive, mental status, speech testing)

96101 PSYCHO TESTING BY No
PSYCH/PHYS

96102 PSYCHO TESTING BY No

TECHNICIAN

96103 PSYCHO TESTING ADMIN No

BY COMP

96105 ASSESSMENT OF APHASIA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 67 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96110 DEVELOPMENTAL No
SCREEN W/SCORE

96111 DEVELOPMENTAL TEST No

EXTEND

96116 NEUROBEHAVIORAL No
STATUS EXAM

96118 NEUROPSYCH TST BY No

PSYCH/PHYS

96119 NEUROPSYCH TESTING No

BY TEC

96120 NEUROPSYCH TST ADMIN No

W/COMP

96125 COGNITIVE TEST BY HC No

PRO

96127 BRIEF No
EMOTIONAL/BEHAV
ASSMT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 68 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

chiropractic manipulative treatment

98940 CHIROPRACT MANJ 1-2 No
REGIONS

98941 CHIROPRACT MANJ 3-4 No

REGIONS

98942 CHIROPRACTIC MANJ 5 No

REGIONS

98943 CHIROPRACT MANJ No

XTRSPINL 1/>

dialysis
90935 HEMODIALYSIS ONE No
EVALUATION

90937 HEMODIALYSIS No
REPEATED EVAL

90940 HEMODIALYSIS ACCESS No

STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 69 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90945 DIALYSIS ONE No

EVALUATION

90947 DIALYSIS REPEATED EVAL No

90951 ESRD SERV 4 VISITS P MO No

<2YR

90952 ESRD SERV 2-3 VSTS P No

MO <2YR

90953 ESRD SERV 1 VISIT P MO No

<2YRS

90954 ESRD SERV 4 VSTS P MO No

2-11

90955 ESRD SRV 2-3 VSTS P MO No

2-11

90956 ESRD SRV 1 VISIT P MO 2- No

11

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 70 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90957 ESRD SRV 4 VSTS P MO No

12-19

90958 ESRD SRV 2-3 VSTS P MO No

12-19

90959 ESRD SERV 1 VST P MO No

12-19

90960 ESRD SRV 4 VISITS P MO No

20+

90961 ESRD SRV 2-3 VSTS P MO No

20+

90962 ESRD SERV 1 VISIT P MO No

20+

90963 ESRD HOME PT SERV P No

MO <2YRS

90964 ESRD HOME PT SERV P No

MO 2-11

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 71 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90965 ESRD HOME PT SERV P No

MO 12-19

90966 ESRD HOME PT SERV P No

MO 20+

90967 ESRD HOME PT SERV P No

DAY <2

90968 ESRD HOME PT SRV P No

DAY 2-11

90969 ESRD HOME PT SRV P No

DAY 12-19

90970 ESRD HOME PT SERV P No

DAY 20+

90989 DIALYSIS TRAINING No

COMPLETE

90993 DIALYSIS TRAINING No

INCOMPL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 72 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90997 HEMOPERFUSION No

90999 DIALYSIS PROCEDURE No

education and training for patient self-management

98960 SELF-MGMT EDUC & No
TRAIN 1 PT

98961 SELF-MGMT EDUC/TRAIN No

2-4 PT

98962 SELF-MGMT EDUC/TRAIN No

5-8 PT

endocrinology
95249 CONT GLUC MNTR PT Yes Please review the Well Sense Policy for Continuous Glucose Monitoring Continuous Glucose
PROV EQP more details Systems and Insulin Delivery Devices Monitoring Systems and
Insulin Delivery Devices (Eff
01/01/19)

95250 GLUCOSE MONITORING Yes Please review the Well Sense Policy for Continuous Glucose Monitoring Continuous Glucose
NH-
CONT more details Systems and Insulin Delivery Devices Monitoring Systems and
Continuous Insulin Delivery Devices (Eff
Glucose
Monitor
01/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 73 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95251 GLUC MONITOR CONT Yes Please review the Well Sense Policy for Continuous Glucose Monitoring Continuous Glucose
NH-
PHYS I&R more details Systems and Insulin Delivery Devices Monitoring Systems and
Continuous Insulin Delivery Devices (Eff
Glucose
Monitor
01/01/19)

gastroenterology
91010 ESOPHAGUS MOTILITY No
STUDY

91013 ESOPHGL MOTIL No

W/STIM/PERFUS

91020 GASTRIC MOTILITY No

STUDIES

91022 DUODENAL MOTILITY No

STUDY

91030 ACID PERFUSION OF No

ESOPHAGUS

91034 GASTROESOPHAGEAL No
REFLUX TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 74 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

91035 G-ESOPH REFLX TST No

W/ELECTROD

91037 ESOPH IMPED FUNCTION No

TEST

91038 ESOPH IMPED FUNCT No

TEST > 1HR

91040 ESOPH BALLOON No

DISTENSION TST

91065 BREATH No
HYDROGEN/METHANE
TEST

91110 GI TRACT CAPSULE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - GI Surgery
ENDOSCOPY *Will be covered only when performed in
the Outpatient setting.

91111 ESOPHAGEAL CAPSULE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - GI Surgery
ENDOSCOPY *Will be covered only when performed in
the Outpatient setting.

91112 GI WIRELESS CAPSULE No

MEASURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 75 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

91117 COLON MOTILITY 6 HR No

STUDY

91120 RECTAL SENSATION TEST No

91122 ANAL PRESSURE RECORD No

91132 ELECTROGASTROGRAPHY No

91133 ELECTROGASTROGRAPHY No
W/TEST

91200 LIVER ELASTOGRAPHY No

91299 GASTROENTEROLOGY No
PROCEDURE

92145 CORNEAL HYSTERESIS No

DETER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 76 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

health and behavior assessment/intervention

96150 ASSESS HLTH/BEHAVE No
INIT

96151 ASSESS HLTH/BEHAVE No

SUBSEQ

96152 INTERVENE No
HLTH/BEHAVE INDIV

96153 INTERVENE No
HLTH/BEHAVE GROUP

96154 INTERV HLTH/BEHAV No

FAM W/PT

96155 INTERV HLTH/BEHAV No

FAM NO PT

home health procedures/services

99500 HOME VISIT PRENATAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 77 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99501 HOME VISIT POSTNATAL Yes Please review the Well Sense Policy for Home Health Care Services for an Home Health Care Services
NH-Home
more details Acute Episode of Care for an Acute EOC (Eff
Health Nursing 05/01/18)

99502 HOME VISIT NB CARE Yes Please review the Well Sense Policy for Home Health Care Services for an Home Health Care Services
NH-Home
more details Acute Episode of Care for an Acute EOC (Eff
Health Nursing 05/01/18)

99503 HOME VISIT RESP No

THERAPY

99504 HOME VISIT MECH No

VENTILATOR

99505 HOME VISIT STOMA CARE No

99506 HOME VISIT IM No

INJECTION

99507 HOME VISIT CATH No

MAINTAIN

99509 HOME VISIT DAY LIFE No

ACTIVITY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 78 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99510 HOME VISIT No

SING/M/FAM COUNS

99511 HOME VISIT No

FECAL/ENEMA MGMT

99512 HOME VISIT FOR No

HEMODIALYSIS

99600 HOME VISIT NOS Yes Please review the Well Sense Policy for Home Health Care Services for an Home Health Care Services
NH-Home
more details Acute Episode of Care for an Acute EOC (Eff
Health Nursing 05/01/18)

99600 HOME VISIT NOS Yes Please review the Well Sense Policy for Home Health Care for Maintenance Home Health Care for
NH-Home
more details Services Maintenance Services ( Eff
Health Nursing 05/01/18)

99601 HOME INFUSION/VISIT 2 No

HRS

99602 HOME INFUSION EACH No

ADDTL HR

hydration, therapeutic, prophylactic, diagnostic injections and infusions, and chemotherapy

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 79 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96360 HYDRATION IV INFUSION No

INIT

96361 HYDRATE IV INFUSION No

ADD-ON

96365 THER/PROPH/DIAG IV INF No

INIT

96366 THER/PROPH/DIAG IV INF No

ADDON

96367 TX/PROPH/DG ADDL SEQ No

IV INF

96368 THER/DIAG No
CONCURRENT INF

96369 SC THER INFUSION UP TO No

1 HR

96370 SC THER INFUSION ADDL No

HR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 80 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96371 SC THER INFUSION RESET No

PUMP

96372 THER/PROPH/DIAG INJ No

SC/IM

96373 THER/PROPH/DIAG INJ IA No

96374 THER/PROPH/DIAG INJ IV No

PUSH

96375 TX/PRO/DX INJ NEW No

DRUG ADDON

96376 TX/PRO/DX INJ SAME No

DRUG ADON

96379 THER/PROP/DIAG INJ/INF No

PROC

96401 CHEMO ANTI-NEOPL No

SQ/IM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 81 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96402 CHEMO HORMON No

ANTINEOPL SQ/IM

96405 CHEMO INTRALESIONAL No

UP TO 7

96406 CHEMO INTRALESIONAL No

OVER 7

96409 CHEMO IV PUSH SNGL No

DRUG

96411 CHEMO IV PUSH ADDL No

DRUG

96413 CHEMO IV INFUSION 1 HR No

96415 CHEMO IV INFUSION No

ADDL HR

96416 CHEMO PROLONG No

INFUSE W/PUMP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 82 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96417 CHEMO IV INFUS EACH No

ADDL SEQ

96420 CHEMO IA PUSH No* *PA req'd if performed as elective proc in

TECNIQUE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

96422 CHEMO IA INFUSION UP No* *PA req'd if performed as elective proc in

TO 1 HR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

96423 CHEMO IA INFUSE EACH No* *PA req'd if performed as elective proc in
ADDL HR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

96425 CHEMOTHERAPY No* *PA req'd if performed as elective proc in

INFUSION METHOD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

96440 CHEMOTHERAPY No
INTRACAVITARY

96446 CHEMOTX ADMN PRTL No

CAVITY

96450 CHEMOTHERAPY INTO No

CNS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 83 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96521 REFILL/MAINT PORTABLE No

PUMP

96522 REFILL/MAINT No
PUMP/RESVR SYST

96523 IRRIG DRUG DELIVERY No

DEVICE

96542 CHEMOTHERAPY No
INJECTION

96549 CHEMOTHERAPY No
UNSPECIFIED

immune globulins, serum or recombinant prods

90281 HUMAN IG IM No

90283 HUMAN IG IV Yes Please review the Well Sense Policy for Immune Globulin Intravenous, Immune Globulin
Other Drugs
more details Subcutaneous (IVIG, SCIG) Intravenous, Subcutaneous
(IVIG, SCIG)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 84 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90284 HUMAN IG SC Yes Please review the Well Sense Policy for Immune Globulin Intravenous, Immune Globulin
NH-Mat
more details Subcutaneous (IVIG, SCIG) Intravenous, Subcutaneous
Drugs/Pharm (IVIG, SCIG)
Copay Waive

90287 BOTULINUM ANTITOXIN No

90288 BOTULISM IG IV No

90291 CMV IG IV No

90296 DIPHTHERIA ANTITOXIN No

90371 HEP B IG IM No

90375 RABIES IG IM/SC No

90376 RABIES IG HEAT TREATED No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 85 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90378 RSV MAB IM 50MG Yes See Pharmacy Policy List of Pharmacy Policies and
Other Drugs
PA Forms

90384 RH IG FULL-DOSE IM No

90385 RH IG MINIDOSE IM No

90386 RH IG IV No

90389 TETANUS IG IM No

90393 VACCINA IG IM No

90396 VARICELLA-ZOSTER IG IM No

90399 IMMUNE GLOBULIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 86 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

immunization administration for vaccines/toxoids

90460 IM ADMIN 1ST/ONLY No
COMPONENT

90461 IM ADMIN EACH ADDL No

COMPONENT

90471 IMMUNIZATION ADMIN No

90472 IMMUNIZATION ADMIN No

EACH ADD

90473 IMMUNE ADMIN No

ORAL/NASAL

90474 IMMUNE ADMIN No

ORAL/NASAL ADDL

medical genetics and genetic counseling services

96040 GENETIC COUNSELING 30 No
MIN

medical nutrition therapy

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 87 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97802 MEDICAL NUTRITION Yes Please review the Well Sense Policy for Medical Nutrition Therapy in the Medical Nutrition Therapy in
NH-Med
INDIV IN more details Outpatient Setting or Office Setting the Outpatient Setting or
Nutrition Office Setting ( Eff 12/01/18)
Ongoing OP

97803 MED NUTRITION INDIV Yes Please review the Well Sense Policy for Medical Nutrition Therapy in the Medical Nutrition Therapy in
NH-Med
SUBSEQ more details Outpatient Setting or Office Setting the Outpatient Setting or
Nutrition Office Setting ( Eff 12/01/18)
Ongoing OP

97804 MEDICAL NUTRITION Yes Please review the Well Sense Policy for Medical Nutrition Therapy in the Medical Nutrition Therapy in
NH-Med
GROUP more details Outpatient Setting or Office Setting the Outpatient Setting or
Nutrition Office Setting ( Eff 12/01/18)
Ongoing OP

medication therapy management services

99605 MTMS BY PHARM NP 15 No
MIN

99606 MTMS BY PHARM EST 15 No

MIN

99607 MTMS BY PHARM ADDL No

15 MIN

neurology and neuromuscular procedures

95782 POLYSOM <6 YRS 4/> No
PARAMTRS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 88 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95783 POLYSOM <6 YRS No

CPAP/BILVL

95800 SLP STDY UNATTENDED Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95801 SLP STDY UNATND Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
W/ANAL ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95803 ACTIGRAPHY TESTING No

95805 MULTIPLE SLEEP Yes* *NOTE: This code does NOT require PA for
NH-IQ-Sleep
LATENCY TEST ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Will be covered only when
performed in the Outpatient setting.

95806 SLEEP STUDY Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
UNATT&RESP EFFT ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95807 SLEEP STUDY ATTENDED Yes* *NOTE: This code does NOT require PA for
NH-IQ-Sleep
ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95808 POLYSOM ANY AGE 1-3> Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
PARAM ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 89 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95810 POLYSOM 6/> YRS 4/> Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
PARAM ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95811 POLYSOM 6/>YRS CPAP Yes* *NOTE: This code does NOT require PA for InterQual® criteria is available
NH-IQ-Sleep
4/> PARM ages 0-6 yrs. Otherwise, InterQual®
Studies criteria used. Provide clinical
documentation supporting rationale for
request.
95812 EEG 41-60 MINUTES No

95813 EEG OVER 1 HOUR No

95816 EEG AWAKE AND No

DROWSY

95819 EEG AWAKE AND ASLEEP No

95822 EEG COMA OR SLEEP No

ONLY

95824 EEG CEREBRAL DEATH No

ONLY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 90 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95827 EEG ALL NIGHT No

RECORDING

95829 SURGERY No
ELECTROCORTICOGRAM

95830 INSERT ELECTRODES FOR No

EEG

95831 LIMB MUSCLE TESTING No

MANUAL

95832 HAND MUSCLE TESTING No

MANUAL

95833 BODY MUSCLE TESTING No

MANUAL

95834 BODY MUSCLE TESTING No

MANUAL

95851 RANGE OF MOTION No

MEASUREMENTS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 91 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95852 RANGE OF MOTION No

MEASUREMENTS

95857 CHOLINESTERASE No
CHALLENGE

95860 MUSCLE TEST ONE LIMB No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95861 MUSCLE TEST 2 LIMBS No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95863 MUSCLE TEST 3 LIMBS No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95864 MUSCLE TEST 4 LIMBS No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95865 MUSCLE TEST LARYNX No

95866 MUSCLE TEST No

HEMIDIAPHRAGM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 92 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95867 MUSCLE TEST CRAN No

NERV UNILAT

95868 MUSCLE TEST CRAN No

NERVE BILAT

95869 MUSCLE TEST THOR No

PARASPINAL

95870 MUSCLE TEST No

NONPARASPINAL

95872 MUSCLE TEST ONE FIBER No

95873 GUIDE NERV DESTR ELEC No

STIM

95874 GUIDE NERV DESTR No

NEEDLE EMG

95875 LIMB EXERCISE TEST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 93 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95885 MUSC TST DONE No* *PA req'd if performed as elective proc in
W/NERV TST LIM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95886 MUSC TEST DONE W/N No* *PA req'd if performed as elective proc in
TEST COMP the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95887 MUSC TST DONE W/N No* *PA req'd if performed as elective proc in
TST NONEXT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95905 MOTOR &/ SENS NRVE No* *PA req'd if performed as elective proc in
CNDJ TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95907 NVR CNDJ TST 1-2 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95908 NRV CNDJ TST 3-4 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95909 NRV CNDJ TST 5-6 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95910 NRV CNDJ TEST 7-8 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 94 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95911 NRV CNDJ TEST 9-10 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95912 NRV CNDJ TEST 11-12 No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95913 NRV CNDJ TEST 13/> No* *PA req'd if performed as elective proc in
STUDIES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95921 AUTONOMIC NRV No* *PA req'd if performed as elective proc in

PARASYM INERVJ the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95922 AUTONOMIC NRV No* *PA req'd if performed as elective proc in

ADRENRG INERVJ the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95923 AUTONOMIC NRV SYST No* *PA req'd if performed as elective proc in
FUNJ TEST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95924 ANS PARASYMP & SYMP No* *PA req'd if performed as elective proc in
W/TILT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

95925 SOMATOSENSORY No
TESTING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 95 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95926 SOMATOSENSORY No
TESTING

95927 SOMATOSENSORY No
TESTING

95928 C MOTOR EVOKED UPPR No

LIMBS

95929 C MOTOR EVOKED LWR No

LIMBS

95930 VISUAL EVOKED No

POTENTIAL TEST

95933 BLINK REFLEX TEST No

95937 NEUROMUSCULAR No
JUNCTION TEST

95938 SOMATOSENSORY No
TESTING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 96 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95939 C MOTOR EVOKED No

UPR&LWR LIMBS

95940 IONM IN OPERATNG No

ROOM 15 MIN

95941 IONM REMOTE/>1 PT OR No

PER HR

95943 PARASYMP&SYMP HRT No

RATE TEST

95950 AMBULATORY EEG No

MONITORING

95951 EEG Yes Please review the Well Sense Policy for Video Electroencephalographic (EEG) Video
NH-Long Term
MONITORING/VIDEOREC more details Monitoring Electroencephalographic
Video EEG ORD (EEG) Monitoring (Eff
Monitor
05/01/18)

95953 EEG No
MONITORING/COMPUTE
R

95954 EEG No
MONITORING/GIVING
DRUGS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 97 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95955 EEG DURING SURGERY No

95956 EEG MONITOR TECHNOL No

ATTENDED

95957 EEG DIGITAL ANALYSIS No

95958 EEG No
MONITORING/FUNCTION
TEST

95961 ELECTRODE No
STIMULATION BRAIN

95962 ELECTRODE STIM BRAIN No

ADD-ON

95965 MEG SPONTANEOUS Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

95966 MEG EVOKED SINGLE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 98 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95967 MEG EVOKED EACH ADDL Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

95970 ANALYZE NEUROSTIM NO No

PROG

95971 ANALYZE NEUROSTIM No

SIMPLE

95972 ANALYZE NEUROSTIM No

COMPLEX

95974 CRANIAL NEUROSTIM No

COMPLEX

95975 CRANIAL NEUROSTIM No

COMPLEX

95978 ANALYZE NEUROSTIM No

BRAIN/1H

95979 ANALYZ NEUROSTIM No

BRAIN ADDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 99 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

95980 IO ANAL GAST N-STIM No Experimental and Investigational Experimental and

INIT Treatment Investigational Treatment (Eff
07/01/18)

95981 IO ANAL GAST N-STIM No Experimental and Investigational Experimental and

SUBSQ Treatment Investigational Treatment (Eff
07/01/18)

95982 IO GA N-STIM SUBSQ No Experimental and Investigational Experimental and

W/REPROG Treatment Investigational Treatment (Eff
07/01/18)

95990 SPIN/BRAIN PUMP REFIL No

& MAIN

95991 SPIN/BRAIN PUMP REFIL No

& MAIN

95992 CANALITH No
REPOSITIONING PROC

95999 NEUROLOGICAL No
PROCEDURE

96000 MOTION ANALYSIS Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
VIDEO/3D more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 100 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96001 MOTION TEST W/FT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
PRESS MEAS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

96002 DYNAMIC SURFACE EMG Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

96003 DYNAMIC FINE WIRE EMG Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

96004 PHYS REVIEW OF Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
MOTION TESTS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

96020 FUNCTIONAL BRAIN No

MAPPING

non-face-to-face nonphysician services

98966 HC PRO PHONE CALL 5- No
10 MIN

98967 HC PRO PHONE CALL 11- No

20 MIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 101 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

98968 HC PRO PHONE CALL 21- No

30 MIN

98969 ONLINE SERVICE BY HC No

PRO

noninvasive vascular diagnostic studies

93880 EXTRACRANIAL BILAT No
STUDY

93882 EXTRACRANIAL UNI/LTD No

STUDY

93886 INTRACRANIAL No
COMPLETE STUDY

93888 INTRACRANIAL LIMITED No

STUDY

93890 TCD VASOREACTIVITY No

STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 102 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93892 TCD EMBOLI DETECT No

W/O INJ

93893 TCD EMBOLI DETECT No

W/INJ

93895 CAROTID INTIMA No

ATHEROMA EVAL

93922 UPR/L XTREMITY ART 2 No

LEVELS

93923 UPR/LXTR ART STDY 3+ No

LVLS

93924 LWR XTR VASC STDY No

BILAT

93925 LOWER EXTREMITY No

STUDY

93926 LOWER EXTREMITY No

STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 103 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93930 UPPER EXTREMITY STUDY No

93931 UPPER EXTREMITY STUDY No

93965 EXTREMITY STUDY No

93970 EXTREMITY STUDY No

93971 EXTREMITY STUDY No

93975 VASCULAR STUDY No

93976 VASCULAR STUDY No

93978 VASCULAR STUDY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 104 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

93979 VASCULAR STUDY No

93980 PENILE VASCULAR STUDY No

93981 PENILE VASCULAR STUDY No

93982 ANEURYSM PRESSURE No

SENS STUDY

93990 DOPPLER FLOW TESTING No

93998 NONINVAS VASC DX No

STUDY PROC

ophthalmology
92002 EYE EXAM NEW PATIENT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 105 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92004 EYE EXAM NEW PATIENT No

92012 EYE EXAM ESTABLISH No

PATIENT

92014 EYE EXAM&TX ESTAB PT No

1/>VST

92015 DETERMINE REFRACTIVE No

STATE

92018 NEW EYE EXAM & No

TREATMENT

92019 EYE EXAM & TREATMENT No

92020 SPECIAL EYE EVALUATION No

92025 CORNEAL TOPOGRAPHY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 106 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92060 SPECIAL EYE EVALUATION No

92065 ORTHOPTIC/PLEOPTIC No
TRAINING

92071 CONTACT LENS FITTING No

FOR TX

92072 FIT CONTAC LENS FOR No

MANAGMNT

92081 VISUAL FIELD No

EXAMINATION(S)

92082 VISUAL FIELD No

EXAMINATION(S)

92083 VISUAL FIELD No

EXAMINATION(S)

92100 SERIAL TONOMETRY No

EXAM(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 107 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92132 CMPTR OPHTH DX IMG No

ANT SEGMT

92133 CMPTR OPHTH IMG No

OPTIC NERVE

92134 CPTR OPHTH DX IMG No

POST SEGMT

92136 OPHTHALMIC BIOMETRY No

92140 GLAUCOMA No
PROVOCATIVE TESTS

92225 SPECIAL EYE EXAM No

INITIAL

92226 SPECIAL EYE EXAM No

SUBSEQUENT

92227 REMOTE DX RETINAL No

IMAGING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 108 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92228 REMOTE RETINAL No

IMAGING MGMT

92230 EYE EXAM WITH PHOTOS No

92235 FLUORESCEIN ANGRPH No

UNI/BI

92240 ICG ANGIOGRAPHY UNI/BI No

92250 EYE EXAM WITH PHOTOS No

92260 OPHTHALMOSCOPY/DYN No
AMOMETRY

92265 EYE MUSCLE EVALUATION No

92270 ELECTRO-OCULOGRAPHY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 109 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92275 ELECTRORETINOGRAPHY No

92283 COLOR VISION No

EXAMINATION

92284 DARK ADAPTATION EYE No

EXAM

92285 EYE PHOTOGRAPHY No

92286 INTERNAL EYE No

PHOTOGRAPHY

92287 INTERNAL EYE No

PHOTOGRAPHY

92310 CONTACT LENS FITTING No

92311 CONTACT LENS FITTING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 110 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92312 CONTACT LENS FITTING No

92313 CONTACT LENS FITTING No

92314 PRESCRIPTION OF No
CONTACT LENS

92315 RX CNTACT LENS No

APHAKIA 1 EYE

92316 RX CNTACT LENS No

APHAKIA 2 EYE

92317 RX CORNEOSCLERAL No
CNTACT LENS

92325 MODIFICATION OF No
CONTACT LENS

92326 REPLACEMENT OF No
CONTACT LENS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 111 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92340 FIT SPECTACLES No

MONOFOCAL

92341 FIT SPECTACLES BIFOCAL No

92342 FIT SPECTACLES No

MULTIFOCAL

92352 FIT APHAKIA SPECTCL No

MONOFOCL

92353 FIT APHAKIA SPECTCL No

MULTIFOC

92354 FIT SPECTACLES SINGLE No

SYSTEM

92355 FIT SPECTACLES No

COMPOUND LENS

92358 APHAKIA PROSTH No

SERVICE TEMP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 112 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92370 REPAIR & ADJUST No

SPECTACLES

92371 REPAIR & ADJUST No

SPECTACLES

92499 EYE SERVICE OR No

PROCEDURE

osteopathic manipulative treatment

98925 OSTEOPATH MANJ 1-2 No
REGIONS

98926 OSTEOPATH MANJ 3-4 No

REGIONS

98927 OSTEOPATH MANJ 5-6 No

REGIONS

98928 OSTEOPATH MANJ 7-8 No

REGIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 113 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

98929 OSTEOPATH MANJ 9-10 No

REGIONS

other services and procedures

99170 ANOGENITAL EXAM No
CHILD W IMAG

99172 OCULAR FUNCTION No

SCREEN

99173 VISUAL ACUITY SCREEN No

99174 OCULAR INSTRUMNT No

SCREEN BIL

99175 INDUCTION OF VOMITING No

99177 OCULAR INSTRUMNT No

SCREEN BIL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 114 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99183 HYPERBARIC OXYGEN Yes Please review the Well Sense Policy for Hyperbaric Oxygen Therapy (HBOT) Hyperbaric Oxygen Therapy Hyperbaric Oxygen
IQ-HBOT
THERAPY more details in the Outpatient Setting (HBOT) in the Outpatient Therapy (HBOT) in the
Hyperbaric Setting ( Eff 02/01/18) outpatient Setting used
Oxygen OP
in Conjuction with

99184 HYPOTHERMIA ILL No

NEONATE

99188 APP TOPICAL FLUORIDE No

VARNISH

99190 SPECIAL PUMP SERVICES No

99191 SPECIAL PUMP SERVICES No

99192 SPECIAL PUMP SERVICES No

99195 PHLEBOTOMY No

99199 SPECIAL No
SERVICE/PROC/REPORT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 115 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

photodynamic therapy
96567 PHOTODYNAMIC TX SKIN No

96570 PHOTODYNMC TX 30 No
MIN ADD-ON

96571 PHOTODYNAMIC TX No
ADDL 15 MIN

physical medicine and rehabilitation

97001 PT EVALUATION No

97003 OT EVALUATION No

97005 ATHLETIC TRAIN EVAL No

97006 ATHLETIC TRAIN REEVAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 116 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97010 HOT OR COLD PACKS Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97010 HOT OR COLD PACKS Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97010 HOT OR COLD PACKS Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97012 MECHANICAL TRACTION Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97012 MECHANICAL TRACTION Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97012 MECHANICAL TRACTION Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97014 ELECTRIC STIMULATION Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup OR Outpatient Setting Older in the Outpatient
Nonimplant
Pelvic
Setting ( Eff 12/01/18)

97014 ELECTRIC STIMULATION Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup OR Outpatient Setting Older in the Outpatient
Nonimplant
Pelvic
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 117 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97014 ELECTRIC STIMULATION Yes Please review the Well Sense Policy for Posterior Tibial Nerve Stimulation Posterior Tibial Nerve Posterior Tibial Nerve
NH-Physical
THERAPY more details Stimulation (Eff 01/01/19 and Stimulation (Eff
OR Occup OR Retired 02/28/19) 03/01/19)
Nonimplant
Pelvic

97014 ELECTRIC STIMULATION Yes Please review the Well Sense Policy for Pelvic Floor Stimulation for the Pelvic Floor Stimulation for Pelvic Floor Stimulation
NH-Physical
THERAPY more details Treatment of Incontinence the Treatment of for the Treatment of
OR Occup OR Incontinence ( Eff 11/01/18 Incontinence ( Eff
Nonimplant
Pelvic
and Retired 02/28/19) 03/01/19)

97014 ELECTRIC STIMULATION Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup OR Setting, Including OT, PT, and/or ST Outpatient Setting, Including
Nonimplant
Pelvic
OT, PT, and/or ST ( Eff

97016 VASOPNEUMATIC DEVICE Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97016 VASOPNEUMATIC DEVICE Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97016 VASOPNEUMATIC DEVICE Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97018 PARAFFIN BATH THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97018 PARAFFIN BATH THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 118 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97018 PARAFFIN BATH THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97022 WHIRLPOOL THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97022 WHIRLPOOL THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97022 WHIRLPOOL THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97024 DIATHERMY EG Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
MICROWAVE more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97024 DIATHERMY EG Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
MICROWAVE more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97024 DIATHERMY EG Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
MICROWAVE more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97026 INFRARED THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 119 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97026 INFRARED THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97026 INFRARED THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97028 ULTRAVIOLET THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97028 ULTRAVIOLET THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97028 ULTRAVIOLET THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97032 ELECTRICAL Yes Please review the Well Sense Policy for Pelvic Floor Stimulation for the Pelvic Floor Stimulation for Pelvic Floor Stimulation
NH-Physical
STIMULATION more details Treatment of Incontinence the Treatment of for the Treatment of
OR Occup OR Incontinence ( Eff 11/01/18 Incontinence ( Eff
Nonimplant
Pelvic
and Retired 02/28/19) 03/01/19)

97032 ELECTRICAL Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
STIMULATION more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup OR Outpatient Setting Older in the Outpatient
Nonimplant
Pelvic
Setting ( Eff 12/01/18)

97032 ELECTRICAL Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
STIMULATION more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup OR Setting, Including OT, PT, and/or ST Outpatient Setting, Including
Nonimplant
Pelvic
OT, PT, and/or ST ( Eff

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 120 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97032 ELECTRICAL Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
STIMULATION more details Years of Age or Older in the Member 21 Years of Age or
OR Occup OR Outpatient Setting Older in the Outpatient
Nonimplant
Pelvic
Setting ( Eff 12/01/18)

97032 ELECTRICAL Yes Please review the Well Sense Policy for Posterior Tibial Nerve Stimulation Posterior Tibial Nerve Posterior Tibial Nerve
NH-Physical
STIMULATION more details Stimulation (Eff 01/01/19 and Stimulation (Eff
OR Occup OR Retired 02/28/19) 03/01/19)
Nonimplant
Pelvic

97033 ELECTRIC CURRENT Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97033 ELECTRIC CURRENT Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97033 ELECTRIC CURRENT Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97034 CONTRAST BATH Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97034 CONTRAST BATH Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97034 CONTRAST BATH Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 121 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97035 ULTRASOUND THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97035 ULTRASOUND THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97035 ULTRASOUND THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97036 HYDROTHERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97036 HYDROTHERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97036 HYDROTHERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97039 PHYSICAL THERAPY No

TREATMENT

97110 THERAPEUTIC EXERCISES Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 122 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97110 THERAPEUTIC EXERCISES Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97110 THERAPEUTIC EXERCISES Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97112 NEUROMUSCULAR Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
REEDUCATION more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97112 NEUROMUSCULAR Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
REEDUCATION more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97112 NEUROMUSCULAR Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
REEDUCATION more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97113 AQUATIC Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
THERAPY/EXERCISES more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97113 AQUATIC Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
THERAPY/EXERCISES more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97113 AQUATIC Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
THERAPY/EXERCISES more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 123 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97116 GAIT TRAINING THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97116 GAIT TRAINING THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97116 GAIT TRAINING THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97124 MASSAGE THERAPY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97124 MASSAGE THERAPY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97124 MASSAGE THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97139 PHYSICAL MEDICINE No

PROCEDURE

97140 MANUAL THERAPY 1/> Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
REGIONS more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 124 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97140 MANUAL THERAPY 1/> Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
REGIONS more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97140 MANUAL THERAPY 1/> Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
REGIONS more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97150 GROUP THERAPEUTIC Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
PROCEDURES more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97150 GROUP THERAPEUTIC Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
PROCEDURES more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97150 GROUP THERAPEUTIC Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
PROCEDURES more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97164 PT RE-EVAL EST PLAN Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
CARE more details Under Age 21 in the Outpatient Member Under Age 21 in the
Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97164 PT RE-EVAL EST PLAN Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
CARE more details Years of Age or Older in the Member 21 Years of Age or
Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97168 OT RE-EVAL EST PLAN Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
CARE more details 21 Years of Age or Older in the Member 21 Years of Age or
Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 125 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97168 OT RE-EVAL EST PLAN Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
CARE more details Under Age 21 in the Outpatient Member Under Age 21 in the
Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97530 THERAPEUTIC ACTIVITIES Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97530 THERAPEUTIC ACTIVITIES Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97530 THERAPEUTIC ACTIVITIES Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97533 SENSORY INTEGRATION Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97533 SENSORY INTEGRATION Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97533 SENSORY INTEGRATION Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97535 SELF CARE MNGMENT Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
TRAINING more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 126 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97535 SELF CARE MNGMENT Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
TRAINING more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97535 SELF CARE MNGMENT Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
TRAINING more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97537 COMMUNITY/WORK Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
REINTEGRATION more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97537 COMMUNITY/WORK Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
REINTEGRATION more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97537 COMMUNITY/WORK Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
REINTEGRATION more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97542 WHEELCHAIR MNGMENT No Functional Therapy for a Member Functional Therapy for a
TRAINING Under Age 21 in the Outpatient Member Under Age 21 in the
Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97545 WORK HARDENING Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97545 WORK HARDENING Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 127 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97545 WORK HARDENING Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97546 WORK HARDENING ADD- Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
ON more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97546 WORK HARDENING ADD- Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
ON more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97546 WORK HARDENING ADD- Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
ON more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97597 RMVL DEVITAL TIS 20 No

CM/<

97598 RMVL DEVITAL TIS ADDL No

20CM/<

97602 TRICHOGRAM No

97605 NEG PRESS WOUND TX No

</=50 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 128 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97606 NEG PRESS WOUND TX No

>50 CM

97607 NEG PRESS WND TX No

</=50 SQ CM

97608 NEG PRESS WOUND TX No

>50 CM

97610 LOW FREQUENCY NON- No

THERMAL US

97750 PHYSICAL PERFORMANCE Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
TEST more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97750 PHYSICAL PERFORMANCE Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
TEST more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97750 PHYSICAL PERFORMANCE Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
TEST more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97755 ASSISTIVE TECHNOLOGY Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
ASSESS more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 129 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97755 ASSISTIVE TECHNOLOGY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
ASSESS more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97755 ASSISTIVE TECHNOLOGY Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
ASSESS more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97760 ORTHOTIC MGMT AND Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
TRAINING more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97760 ORTHOTIC MGMT AND Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
TRAINING more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97760 ORTHOTIC MGMT AND Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
TRAINING more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97761 PROSTHETIC TRAINING Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97761 PROSTHETIC TRAINING Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97761 PROSTHETIC TRAINING Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 130 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

97763 ORTHC/PROSTC MGMT Yes Please review the Well Sense Policy for Occupational Therapy for a Member Occupational Therapy for a
NH-Physical
SBSQ ENC more details 21 Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97763 ORTHC/PROSTC MGMT Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Physical
SBSQ ENC more details Under Age 21 in the Outpatient Member Under Age 21 in the
OR Occup Ther Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

97763 ORTHC/PROSTC MGMT Yes Please review the Well Sense Policy for Physical Therapy for a Member 21 Physical Therapy for a
NH-Physical
SBSQ ENC more details Years of Age or Older in the Member 21 Years of Age or
OR Occup Ther Outpatient Setting Older in the Outpatient
Setting ( Eff 12/01/18)

97799 PHYSICAL MEDICINE No

PROCEDURE

psychiatry
90785 PSYTX COMPLEX No
INTERACTIVE

90791 PSYCH DIAGNOSTIC No

EVALUATION

90792 PSYCH DIAG EVAL No

W/MED SRVCS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 131 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90832 PSYTX W PT 30 MINUTES No

90833 PSYTX W PT W E/M 30 No

MIN

90834 PSYTX W PT 45 MINUTES No

90836 PSYTX W PT W E/M 45 No

MIN

90837 PSYTX W PT 60 MINUTES No

90838 PSYTX W PT W E/M 60 No

MIN

90839 PSYTX CRISIS INITIAL 60 No

MIN

90840 PSYTX CRISIS EA ADDL 30 No

MIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 132 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90845 PSYCHOANALYSIS No

90846 FAMILY PSYTX W/O PT 50 No

MIN

90847 FAMILY PSYTX W/PT 50 No

MIN

90849 MULTIPLE FAMILY No

GROUP PSYTX

90853 GROUP PSYCHOTHERAPY No

90863 PHARMACOLOGIC MGMT No

W/PSYTX

90865 NARCOSYNTHESIS No

90867 TCRANIAL MAGN STIM TX No

PLAN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 133 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90868 TCRANIAL MAGN STIM TX No

DELI

90869 TCRAN MAGN STIM No

REDETEMINE

90870 ELECTROCONVULSIVE No
THERAPY

90875 PSYCHOPHYSIOLOGICAL No
THERAPY

90876 PSYCHOPHYSIOLOGICAL No
THERAPY

90880 HYPNOTHERAPY No

90882 ENVIRONMENTAL No
MANIPULATION

90885 PSY EVALUATION OF No

RECORDS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 134 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90887 CONSULTATION WITH No

FAMILY

90889 PREPARATION OF REPORT No

90899 PSYCHIATRIC No
SERVICE/THERAPY

pulmonary
94002 VENT MGMT INPAT INIT No
DAY

94003 VENT MGMT INPAT SUBQ No

DAY

94004 VENT MGMT NF PER DAY No

94005 HOME VENT MGMT No

SUPERVISION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 135 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94010 BREATHING CAPACITY No

TEST

94011 SPIROMETRY UP TO 2 No
YRS OLD

94012 SPIRMTRY W/BRNCHDIL No

INF-2 YR

94013 MEAS LUNG VOL THRU 2 No

YRS

94014 PATIENT RECORDED No

SPIROMETRY

94015 PATIENT RECORDED No

SPIROMETRY

94016 REVIEW PATIENT No

SPIROMETRY

94060 EVALUATION OF No
WHEEZING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 136 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94070 EVALUATION OF No
WHEEZING

94150 VITAL CAPACITY TEST No

94200 LUNG FUNCTION TEST No

(MBC/MVV)

94250 EXPIRED GAS COLLECTION No

94375 RESPIRATORY FLOW No

VOLUME LOOP

94400 CO2 BREATHING No

RESPONSE CURVE

94450 HYPOXIA RESPONSE No

CURVE

94452 HAST W/REPORT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 137 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94453 HAST W/OXYGEN TITRATE No

94610 SURFACTANT ADMIN No

THRU TUBE

94620 PULMONARY STRESS No

TEST/SIMPLE

94621 PULM STRESS No

TEST/COMPLEX

94640 AIRWAY INHALATION No

TREATMENT

94642 AEROSOL INHALATION No

TREATMENT

94644 CBT 1ST HOUR No

94645 CBT EACH ADDL HOUR No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 138 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94660 POS AIRWAY PRESSURE No

CPAP

94662 NEG PRESS VENTILATION No

CNP

94664 EVALUATE PT USE OF No

INHALER

94667 CHEST WALL No

MANIPULATION

94668 CHEST WALL No

MANIPULATION

94669 MECHANICAL CHEST No

WALL OSCILL

94680 EXHALED AIR ANALYSIS No

O2

94681 EXHALED AIR ANALYSIS No

O2/CO2

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 139 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94690 EXHALED AIR ANALYSIS No

94726 PULM FUNCT TST No

PLETHYSMOGRAP

94727 PULM FUNCTION TEST BY No

GAS

94728 PULM FUNCT TEST No

OSCILLOMETRY

94729 CO/MEMBANE DIFFUSE No

CAPACITY

94750 PULMONARY No
COMPLIANCE STUDY

94760 MEASURE BLOOD No

OXYGEN LEVEL

94761 MEASURE BLOOD No

OXYGEN LEVEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 140 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94762 MEASURE BLOOD No

OXYGEN LEVEL

94770 EXHALED CARBON No

DIOXIDE TEST

94772 BREATH RECORDING No

INFANT

94774 PED HOME APNEA REC No

COMPL

94775 PED HOME APNEA REC No

HK-UP

94776 PED HOME APNEA REC No

DOWNLD

94777 PED HOME APNEA REC No

REPORT

94780 CAR SEAT/BED TEST 60 No

MIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 141 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

94781 CAR SEAT/BED TEST + 30 No

MIN

94799 PULMONARY No
SERVICE/PROCEDURE

special dermatological procedures

96900 ULTRAVIOLET LIGHT No* *Effective 3/1/16 The DX codes will waive Photochemotherapy or Photochemotherapy or
NH-
THERAPY the auth requirement Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96900 ULTRAVIOLET LIGHT No* *Effective 3/1/16 The DX codes will waive Photochemotherapy or Photochemotherapy or
NH-
THERAPY the auth requirement Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96902 TRICHOGRAM No

96904 WHOLE BODY Yes Please review the Well Sense Policy for Whole Body Integumentary Whole Body Integumentary
NH-
PHOTOGRAPHY more details Photography and Dermatoscopy Photography and
Experimental/I Dermatoscopy (Eff10/01/18)
nvestigation

96910 PHOTOCHEMOTHERAPY Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
WITH UV-B more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 142 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96912 PHOTOCHEMOTHERAPY Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
WITH UV-A more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96913 PHOTOCHEMOTHERAPY Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
UV-A OR B more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96920 LASER TX SKIN < 250 SQ Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
CM more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96921 LASER TX SKIN 250-500 Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
SQ CM more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96922 LASER TX SKIN >500 SQ Yes Please review the Well Sense Policy for Photochemotherapy or Photochemotherapy or
NH-
CM more details Phototherapy for Dermatological Phototherapy for
Photo/Photoch Conditions in the Outpatient Setting Dermatological Conditions in
emotherapy
the Outpatient Setting ( Eff

96931 RCM CELULR SUBCELULR No

IMG SKN

96932 RCM CELULR SUBCELULR No

IMG SKN

96933 RCM CELULR SUBCELULR No

IMG SKN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 143 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

96934 RCM CELULR SUBCELULR No

IMG SKN

96935 RCM CELULR SUBCELULR No

IMG SKN

96936 RCM CELULR SUBCELULR No

IMG SKN

96999 DERMATOLOGICAL No
PROCEDURE

special otorhinolaryngologic services

92502 EAR AND THROAT No
EXAMINATION

92504 EAR MICROSCOPY No

EXAMINATION

92507 SPEECH/HEARING Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Speech
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
Therapy OP Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 144 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92507 SPEECH/HEARING Yes Please review the Well Sense Policy for Speech Therapy, Language Therapy, Speech Therapy, Language
NH-Speech
THERAPY more details Voice Therapy, or Auditory Therapy, Voice Therapy, or
Therapy OP Rehabilitation for a Member Age 21 Auditory Rehabilitation for a
Years of Age or Older in the Member Age 21 Years of Age
Outpatient Setting
92508 SPEECH/HEARING Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Speech
THERAPY more details Under Age 21 in the Outpatient Member Under Age 21 in the
Therapy OP Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

92508 SPEECH/HEARING Yes Please review the Well Sense Policy for Speech Therapy, Language Therapy, Speech Therapy, Language
NH-Speech
THERAPY more details Voice Therapy, or Auditory Therapy, Voice Therapy, or
Therapy OP Rehabilitation for a Member Age 21 Auditory Rehabilitation for a
Years of Age or Older in the Member Age 21 Years of Age
Outpatient Setting
92511 NASOPHARYNGOSCOPY No

92512 NASAL FUNCTION No

STUDIES

92516 FACIAL NERVE FUNCTION No

TEST

92520 LARYNGEAL FUNCTION No

STUDIES

92521 EVALUATION OF SPEECH No

FLUENCY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 145 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92522 EVALUATE SPEECH No

PRODUCTION

92523 SPEECH SOUND LANG No

COMPREHEN

92524 BEHAVRAL QUALIT No

ANALYS VOICE

92526 ORAL FUNCTION THERAPY Yes Please review the Well Sense Policy for Functional Therapy for a Member Functional Therapy for a
NH-Speech
more details Under Age 21 in the Outpatient Member Under Age 21 in the
Therapy OP Setting, Including OT, PT, and/or ST Outpatient Setting, Including
OT, PT, and/or ST ( Eff

92526 ORAL FUNCTION THERAPY Yes Please review the Well Sense Policy for Speech Therapy, Language Therapy, Speech Therapy, Language
NH-Speech
more details Voice Therapy, or Auditory Therapy, Voice Therapy, or
Therapy OP Rehabilitation for a Member Age 21 Auditory Rehabilitation for a
Years of Age or Older in the Member Age 21 Years of Age
Outpatient Setting
92531 SPONTANEOUS No
NYSTAGMUS STUDY

92532 POSITIONAL NYSTAGMUS No

TEST

92533 CALORIC VESTIBULAR No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 146 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92534 OPTOKINETIC No
NYSTAGMUS TEST

92537 CALORIC VSTBLR TEST No

W/REC

92538 CALORIC VSTBLR TEST No

W/REC

92540 BASIC VESTIBULAR No

EVALUATION

92541 SPONTANEOUS No
NYSTAGMUS TEST

92542 POSITIONAL NYSTAGMUS No

TEST

92544 OPTOKINETIC No
NYSTAGMUS TEST

92545 OSCILLATING TRACKING No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 147 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92546 SINUSOIDAL No
ROTATIONAL TEST

92547 SUPPLEMENTAL No
ELECTRICAL TEST

92548 POSTUROGRAPHY No

92550 TYMPANOMETRY & No

REFLEX THRESH

92551 PURE TONE HEARING No

TEST AIR

92552 PURE TONE No

AUDIOMETRY AIR

92553 AUDIOMETRY AIR & BONE No

92555 SPEECH THRESHOLD No

AUDIOMETRY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 148 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92556 SPEECH AUDIOMETRY No

COMPLETE

92557 COMPREHENSIVE No
HEARING TEST

92558 EVOKED AUDITORY TEST No

QUAL

92559 GROUP AUDIOMETRIC No

TESTING

92560 BEKESY AUDIOMETRY No

SCREEN

92561 BEKESY AUDIOMETRY No

DIAGNOSIS

92562 LOUDNESS BALANCE TEST No

92563 TONE DECAY HEARING No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 149 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92564 SISI HEARING TEST No

92565 STENGER TEST PURE No

TONE

92567 TYMPANOMETRY No

92568 ACOUSTIC REFL No

THRESHOLD TST

92570 ACOUSTIC IMMITANCE No

TESTING

92571 FILTERED SPEECH No

HEARING TEST

92572 STAGGERED SPONDAIC No

WORD TEST

92575 SENSORINEURAL ACUITY No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 150 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92576 SYNTHETIC SENTENCE No

TEST

92577 STENGER TEST SPEECH No

92579 VISUAL AUDIOMETRY No

(VRA)

92582 CONDITIONING PLAY No

AUDIOMETRY

92583 SELECT PICTURE No

AUDIOMETRY

92584 ELECTROCOCHLEOGRAPH No
Y

92585 AUDITOR EVOKE POTENT No

COMPRE

92586 AUDITOR EVOKE POTENT No

LIMIT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 151 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92587 EVOKED AUDITORY TEST No

LIMITED

92588 EVOKED AUDITORY TST No

COMPLETE

92590 HEARING AID EXAM ONE No

EAR

92591 HEARING AID EXAM No

BOTH EARS

92592 HEARING AID CHECK ONE No

EAR

92593 HEARING AID CHECK No

BOTH EARS

92594 ELECTRO HEARNG AID No

TEST ONE

92595 ELECTRO HEARNG AID No

TST BOTH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 152 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92596 EAR PROTECTOR No

EVALUATION

92597 ORAL SPEECH DEVICE No

EVAL

92601 COCHLEAR IMPLT F/UP No

EXAM <7

92602 REPROGRAM COCHLEAR No

IMPLT 7/>

92603 COCHLEAR IMPLT F/UP No

EXAM 7/>

92604 REPROGRAM COCHLEAR No

IMPLT 7/>

92605 EX FOR NONSPEECH No

DEVICE RX

92606 NON-SPEECH DEVICE No

SERVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 153 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92607 EX FOR SPEECH DEVICE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
RX 1HR more details Treatment Investigational Treatmen
Experimental/I
nvestigation

92608 EX FOR SPEECH DEVICE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
RX ADDL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

92609 USE OF SPEECH DEVICE No

SERVICE

92610 EVALUATE SWALLOWING No

FUNCTION

92611 MOTION Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
FLUOROSCOPY/SWALLO more details Treatment Investigational Treatment (Eff
Experimental/I W 07/01/18)
nvestigation

92612 ENDOSCOPY SWALLOW No

(FEES) VID

92613 ENDOSCOPY SWALLOW No

(FEES) I&R

92614 LARYNGOSCOPIC No
SENSORY VID

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 154 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92615 LARYNGOSCOPIC No
SENSORY I&R

92616 FEES W/LARYNGEAL Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
SENSE TEST more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

92617 FEES W/LARYNGEAL No

SENSE I&R

92618 EX FOR NONSPEECH DEV No

RX ADD

92620 AUDITORY FUNCTION 60 Yes Please review the Well Sense Policy for Central Auditory Function Evaluation Central Auditory Function
MIN more details to Diagnose Central Auditory Evaluation to Diagnose
Processing Disorder Central Auditory Processing
Disorder (Eff 07/01/18)

92621 AUDITORY FUNCTION + Yes Please review the Well Sense Policy for Central Auditory Function Evaluation Central Auditory Function
15 MIN more details to Diagnose Central Auditory Evaluation to Diagnose
Processing Disorder Central Auditory Processing
Disorder (Eff 07/01/18)

92625 TINNITUS ASSESSMENT No

92626 EVAL AUD REHAB STATUS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 155 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

92627 EVAL AUD STATUS REHAB No

ADD-ON

92630 AUD REHAB PRE-LING No

HEAR LOSS

92633 AUD REHAB POSTLING No

HEAR LOSS

92640 AUD BRAINSTEM IMPLT No

PROGRAMG

92700 ENT PROCEDURE/SERVICE No

special services, procedures and reports

99000 SPECIMEN HANDLING No
OFFICE-LAB

99001 SPECIMEN HANDLING PT- No

LAB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 156 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99002 DEVICE HANDLING No

PHYS/QHP

99024 POSTOP FOLLOW-UP No

VISIT

99026 IN-HOSPITAL ON CALL No

SERVICE

99027 OUT-OF-HOSP ON CALL No

SERVICE

99050 MEDICAL SERVICES No

AFTER HRS

99051 MED SERV No

EVE/WKEND/HOLIDAY

99053 MED SERV 10PM-8AM 24 No

HR FAC

99056 MED SERVICE OUT OF No

OFFICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 157 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99058 OFFICE EMERGENCY CARE No

99060 OUT OF OFFICE EMERG No

MED SERV

99070 SPECIAL SUPPLIES No

PHYS/QHP

99071 PATIENT EDUCATION No

MATERIALS

99075 MEDICAL TESTIMONY No

99078 GROUP HEALTH No

EDUCATION

99080 SPECIAL REPORTS OR No

FORMS

99082 UNUSUAL PHYSICIAN No

TRAVEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 158 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99090 COMPUTER DATA No

ANALYSIS

99091 COLLECT/REVIEW DATA No

FROM PT

vaccines, toxoids
90476 ADENOVIRUS VACCINE No
TYPE 4

90477 ADENOVIRUS VACCINE No

TYPE 7

90581 ANTHRAX VACCINE SC OR No

IM

90585 BCG VACCINE PERCUT No

90586 BCG VACCINE No

INTRAVESICAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 159 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90620 MENB RP W/OMV No

VACCINE IM

90621 MENB RLP VACCINE IM No

90625 CHOLERA VACCINE LIVE No

ORAL

90630 FLU VACC IIV4 NO No

PRESERV ID

90632 HEP A VACCINE ADULT IM No

90633 HEPA VACC PED/ADOL 2 No

DOSE

90634 HEPA VACC PED/ADOL 3 No

DOSE

90636 HEP A/HEP B VACC No

ADULT IM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 160 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90644 HIB-MENCY VACCINE 4 No

DOSE IM

90647 HIB PRP-OMP VACC 3 No

DOSE IM

90648 HIB PRP-T VACCINE 4 No

DOSE IM

90649 4VHPV VACCINE 3 DOSE Yes Please review the Well Sense Policy for Vaccines - Gardasil®, Cervarix®, Vaccines - Gardasil®,
Other Drugs
IM more details Zostavax® Cervarix®, Zostavax®

90650 2VHPV VACCINE 3 DOSE Yes Please review the Well Sense Policy for Vaccines - Gardasil®, Cervarix®, Vaccines - Gardasil®,
Other Drugs
IM more details Zostavax® Cervarix®, Zostavax®

90651 9VHPV VACCINE 3 DOSE Yes Please review the Well Sense Policy for Vaccines - Gardasil®, Cervarix®, Vaccines - Gardasil®,
Other Drugs
IM more details Zostavax® Cervarix®, Zostavax®

90653 IIV ADJUVANT VACCINE No

IM

90654 FLU VACC IIV3 NO No

PRESERV ID

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 161 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90655 IIV3 VACC NO PRSV 0.25 No

ML IM

90656 IIV3 VACC NO PRSV 0.5 No

ML IM

90657 IIV3 VACCINE SPLT 0.25 No

ML IM

90658 IIV3 VACCINE SPLT 0.5 No

ML IM

90660 LAIV3 VACCINE No

INTRANASAL

90661 CCIIV3 VAC NO PRSV 0.5 Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ML IM more details Treatment Investigational Treatmen
Experimental/I
nvestigation

90662 IIV NO PRSV INCREASED No

AG IM

90664 LAIV VACC PANDEMIC No

INTRANASL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 162 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90666 FLU VAC PANDEM PRSRV No

FREE IM

90667 IIV VACC PANDEMIC No

ADJUVT IM

90668 IIV VACCINE PANDEMIC No

IM

90670 PCV13 VACCINE IM No

90672 LAIV4 VACCINE No

INTRANASAL

90673 RIV3 VACCINE NO No

PRESERV IM

90675 RABIES VACCINE IM No

90676 RABIES VACCINE ID No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 163 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90680 RV5 VACC 3 DOSE LIVE No

ORAL

90681 RV1 VACC 2 DOSE LIVE No

ORAL

90685 IIIIV4 VACC NO PRSV 0.25 No

ML IM

90686 IIV4 VACC NO PRSV 0.5 No

ML IM

90687 IIV4 VACCINE SPLT 0.25 No

ML IM

90688 IIV4 VACCINE SPLT 0.5 No

ML IM

90690 TYPHOID VACCINE ORAL No

90691 TYPHOID VACCINE IM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 164 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90696 DTAP-IPV VACCINE 4-6 No

YRS IM

90697 DTAP-IPV-HIB-HEPB No
VACCINE IM

90698 DTAP-IPV/HIB VACCINE No

IM

90700 DTAP VACCINE < 7 YRS IM No

90702 DT VACCINE UNDER 7 No

YRS IM

90707 MMR VACCINE SC No

90710 MMRV VACCINE SC No

90713 POLIOVIRUS IPV SC/IM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 165 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90714 TD VACC NO PRESV 7 No

YRS+ IM

90715 TDAP VACCINE 7 YRS/> IM No

90716 VAR VACCINE LIVE SUBQ No

90717 YELLOW FEVER VACCINE No

SUBQ

90723 DTAP-HEP B-IPV VACCINE No

IM

90732 PPSV23 VACC 2 YRS+ No

SUBQ/IM

90733 MPSV4 VACCINE SUBQ No

90734 MCV4 MENACWY No

VACCINE IM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 166 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90736 HZV VACCINE LIVE SUBQ Yes Please review the Well Sense Policy for Vaccines - Gardasil®, Cervarix®, Vaccines - Gardasil®,
Other Drugs
more details Zostavax® Cervarix®, Zostavax®

90738 INACTIVATED JE VACC IM No

90739 HEPB VACC 2 DOSE No

ADULT IM

90740 HEPB VACC 3 DOSE No

IMMUNSUP IM

90743 HEPB VACC 2 DOSE No

ADOLESC IM

90744 HEPB VACC 3 DOSE No

PED/ADOL IM

90746 HEPB VACCINE 3 DOSE No

ADULT IM

90747 HEPB VACC 4 DOSE No

IMMUNSUP IM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 167 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

90748 HIB-HEPB VACCINE IM No

90749 VACCINE TOXOID No

Codes for Pathology and Laboratory

anatomic pathology (postmortem)
88000 AUTOPSY (NECROPSY) No
GROSS

88005 AUTOPSY (NECROPSY) No

GROSS

88007 AUTOPSY (NECROPSY) No

GROSS

88012 AUTOPSY (NECROPSY) No

GROSS

88014 AUTOPSY (NECROPSY) No

GROSS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 168 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88016 AUTOPSY (NECROPSY) No

GROSS

88020 AUTOPSY (NECROPSY) No

COMPLETE

88025 AUTOPSY (NECROPSY) No

COMPLETE

88027 AUTOPSY (NECROPSY) No

COMPLETE

88028 AUTOPSY (NECROPSY) No

COMPLETE

88029 AUTOPSY (NECROPSY) No

COMPLETE

88036 LIMITED AUTOPSY No

88037 LIMITED AUTOPSY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 169 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88040 FORENSIC AUTOPSY No

(NECROPSY)

88045 CORONERS AUTOPSY No

(NECROPSY)

88099 NECROPSY (AUTOPSY) No

PROCEDURE

chemistry
82009 TEST FOR No
ACETONE/KETONES

82010 ACETONE ASSAY No

82013 ACETYLCHOLINESTERASE No
ASSAY

82016 ACYLCARNITINES QUAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 170 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82017 ACYLCARNITINES QUANT No

82024 ASSAY OF ACTH No

82030 ASSAY OF ADP & AMP No

82040 ASSAY OF SERUM No

ALBUMIN

82042 ASSAY OF URINE No

ALBUMIN

82043 MICROALBUMIN No
QUANTITATIVE

82044 MICROALBUMIN No
SEMIQUANT

82045 ALBUMIN ISCHEMIA No

MODIFIED

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 171 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82075 ASSAY OF BREATH No

ETHANOL

82085 ASSAY OF ALDOLASE No

82088 ASSAY OF ALDOSTERONE No

82103 ALPHA-1-ANTITRYPSIN No
TOTAL

82104 ALPHA-1-ANTITRYPSIN No
PHENO

82105 ALPHA-FETOPROTEIN No
SERUM

82106 ALPHA-FETOPROTEIN No
AMNIOTIC

82107 ALPHA-FETOPROTEIN L3 No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 172 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82108 ASSAY OF ALUMINUM No

82120 AMINES VAGINAL FLUID No

QUAL

82127 AMINO ACID SINGLE No

QUAL

82128 AMINO ACIDS MULT No

QUAL

82131 AMINO ACIDS SINGLE No

QUANT

82135 ASSAY AMINOLEVULINIC No

ACID

82136 AMINO ACIDS QUANT 2-5 No

82139 AMINO ACIDS QUAN 6 No

OR MORE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 173 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82140 ASSAY OF AMMONIA No

82143 AMNIOTIC FLUID SCAN No

82150 ASSAY OF AMYLASE No

82154 ANDROSTANEDIOL No
GLUCURONIDE

82157 ASSAY OF No
ANDROSTENEDIONE

82160 ASSAY OF No
ANDROSTERONE

82163 ASSAY OF ANGIOTENSIN II No

82164 ANGIOTENSIN I ENZYME No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 174 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82172 ASSAY OF No
APOLIPOPROTEIN

82175 ASSAY OF ARSENIC No

82180 ASSAY OF ASCORBIC ACID No

82190 ATOMIC ABSORPTION No

82232 ASSAY OF BETA-2 No

PROTEIN

82239 BILE ACIDS TOTAL No

82240 BILE ACIDS No

CHOLYLGLYCINE

82247 BILIRUBIN TOTAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 175 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82248 BILIRUBIN DIRECT No

82252 FECAL BILIRUBIN TEST No

82261 ASSAY OF BIOTINIDASE No

82270 OCCULT BLOOD FECES No

82271 OCCULT BLOOD OTHER No

SOURCES

82272 OCCULT BLD FECES 1-3 No

TESTS

82274 ASSAY TEST FOR BLOOD No

FECAL

82286 ASSAY OF BRADYKININ No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 176 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82300 ASSAY OF CADMIUM No

82306 VITAMIN D 25 HYDROXY No

82308 ASSAY OF CALCITONIN No

82310 ASSAY OF CALCIUM No

82330 ASSAY OF CALCIUM No

82331 CALCIUM INFUSION TEST No

82340 ASSAY OF CALCIUM IN No

URINE

82355 CALCULUS ANALYSIS No

QUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 177 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82360 CALCULUS ASSAY QUANT No

82365 CALCULUS No
SPECTROSCOPY

82370 X-RAY ASSAY CALCULUS No

82373 ASSAY C-D TRANSFER No

MEASURE

82374 ASSAY BLOOD CARBON No

DIOXIDE

82375 ASSAY CARBOXYHB No

QUANT

82376 ASSAY CARBOXYHB QUAL No

82378 CARCINOEMBRYONIC No
ANTIGEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 178 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82379 ASSAY OF CARNITINE No

82380 ASSAY OF CAROTENE No

82382 ASSAY URINE No

CATECHOLAMINES

82383 ASSAY BLOOD No

CATECHOLAMINES

82384 ASSAY THREE No

CATECHOLAMINES

82387 ASSAY OF CATHEPSIN-D No

82390 ASSAY OF No
CERULOPLASMIN

82397 CHEMILUMINESCENT No
ASSAY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 179 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82415 ASSAY OF No
CHLORAMPHENICOL

82435 ASSAY OF BLOOD No

CHLORIDE

82436 ASSAY OF URINE No

CHLORIDE

82438 ASSAY OTHER FLUID No

CHLORIDES

82441 TEST FOR No

CHLOROHYDROCARBONS

82465 ASSAY BLD/SERUM No

CHOLESTEROL

82480 ASSAY SERUM No

CHOLINESTERASE

82482 ASSAY RBC No

CHOLINESTERASE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 180 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82485 ASSAY CHONDROITIN No

SULFATE

82495 ASSAY OF CHROMIUM No

82507 ASSAY OF CITRATE No

82523 COLLAGEN CROSSLINKS No

82525 ASSAY OF COPPER No

82528 ASSAY OF No
CORTICOSTERONE

82530 CORTISOL FREE No

82533 TOTAL CORTISOL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 181 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82540 ASSAY OF CREATINE No

82542 COL CHROMOTOGRAPHY No

QUAL/QUAN

82550 ASSAY OF CK (CPK) No

82552 ASSAY OF CPK IN BLOOD No

82553 CREATINE MB FRACTION No

82554 CREATINE ISOFORMS No

82565 ASSAY OF CREATININE No

82570 ASSAY OF URINE No

CREATININE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 182 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82575 CREATININE CLEARANCE No

TEST

82585 ASSAY OF No
CRYOFIBRINOGEN

82595 ASSAY OF CRYOGLOBULIN No

82600 ASSAY OF CYANIDE No

82607 VITAMIN B-12 No

82608 B-12 BINDING CAPACITY No

82610 CYSTATIN C No

82615 TEST FOR URINE CYSTINES No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 183 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82626 DEHYDROEPIANDROSTER No
ONE

82627 DEHYDROEPIANDROSTER No
ONE

82633 DESOXYCORTICOSTERONE No

82634 DEOXYCORTISOL No

82638 ASSAY OF DIBUCAINE No

NUMBER

82652 VIT D 1 25-DIHYDROXY No

82656 PANCREATIC ELASTASE No

FECAL

82657 ENZYME CELL ACTIVITY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 184 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82658 ENZYME CELL ACTIVITY No

RA

82664 ELECTROPHORETIC TEST No

82668 ASSAY OF No
ERYTHROPOIETIN

82670 ASSAY OF ESTRADIOL No

82671 ASSAY OF ESTROGENS No

82672 ASSAY OF ESTROGEN No

82677 ASSAY OF ESTRIOL No

82679 ASSAY OF ESTRONE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 185 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82693 ASSAY OF ETHYLENE No

GLYCOL

82696 ASSAY OF No
ETIOCHOLANOLONE

82705 FATS/LIPIDS FECES QUAL No

82710 FATS/LIPIDS FECES No

QUANT

82715 ASSAY OF FECAL FAT No

82725 ASSAY OF BLOOD FATTY No

ACIDS

82726 LONG CHAIN FATTY ACIDS No

82728 ASSAY OF FERRITIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 186 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82731 ASSAY OF FETAL No

FIBRONECTIN

82735 ASSAY OF FLUORIDE No

82746 ASSAY OF FOLIC ACID No

SERUM

82747 ASSAY OF FOLIC ACID RBC No

82757 ASSAY OF SEMEN No

FRUCTOSE

82759 ASSAY OF RBC No

GALACTOKINASE

82760 ASSAY OF GALACTOSE No

82775 ASSAY GALACTOSE No

TRANSFERASE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 187 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82776 GALACTOSE No
TRANSFERASE TEST

82777 GALECTIN-3 No

82784 ASSAY IGA/IGD/IGG/IGM No

EACH

82785 ASSAY OF IGE No

82787 IGG 1 2 3 OR 4 EACH No

82800 BLOOD PH No

82803 BLOOD GASES ANY No

COMBINATION

82805 BLOOD GASES W/O2 No

SATURATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 188 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82810 BLOOD GASES O2 SAT No

ONLY

82820 HEMOGLOBIN-OXYGEN No
AFFINITY

82930 GASTRIC ANALY W/PH EA No

SPEC

82938 GASTRIN TEST No

82941 ASSAY OF GASTRIN No

82943 ASSAY OF GLUCAGON No

82945 GLUCOSE OTHER FLUID No

82946 GLUCAGON TOLERANCE No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 189 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82947 ASSAY GLUCOSE BLOOD No

QUANT

82948 REAGENT STRIP/BLOOD No

GLUCOSE

82950 GLUCOSE TEST No

82951 GLUCOSE TOLERANCE No

TEST (GTT)

82952 GTT-ADDED SAMPLES No

82955 ASSAY OF G6PD ENZYME No

82960 TEST FOR G6PD ENZYME No

82962 GLUCOSE BLOOD TEST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 190 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

82963 ASSAY OF GLUCOSIDASE No

82965 ASSAY OF GDH ENZYME No

82977 ASSAY OF GGT No

82978 ASSAY OF GLUTATHIONE No

82979 ASSAY RBC GLUTATHIONE No

82985 ASSAY OF GLYCATED No

PROTEIN

83001 ASSAY OF No
GONADOTROPIN (FSH)

83002 ASSAY OF No
GONADOTROPIN (LH)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 191 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83003 ASSAY GROWTH No

HORMONE (HGH)

83006 GROWTH STIMULATION No

GENE 2

83009 H PYLORI (C-13) BLOOD No

83010 ASSAY OF HAPTOGLOBIN No

QUANT

83012 ASSAY OF HAPTOGLOBINS No

83013 H PYLORI (C-13) BREATH No

83014 H PYLORI DRUG ADMIN No

83015 HEAVY METAL QUAL ANY No

ANAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 192 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83018 HEAVY METAL QUANT No

EACH NES

83020 HEMOGLOBIN No
ELECTROPHORESIS

83021 HEMOGLOBIN No
CHROMOTOGRAPHY

83026 HEMOGLOBIN COPPER No

SULFATE

83030 FETAL HEMOGLOBIN No

CHEMICAL

83033 FETAL HEMOGLOBIN No

ASSAY QUAL

83036 GLYCOSYLATED No
HEMOGLOBIN TEST

83037 GLYCOSYLATED HB No
HOME DEVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 193 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83045 BLOOD No
METHEMOGLOBIN TEST

83050 BLOOD No
METHEMOGLOBIN ASSAY

83051 ASSAY OF PLASMA No

HEMOGLOBIN

83060 BLOOD No
SULFHEMOGLOBIN ASSAY

83065 ASSAY OF HEMOGLOBIN No

HEAT

83068 HEMOGLOBIN STABILITY No

SCREEN

83069 ASSAY OF URINE No

HEMOGLOBIN

83070 ASSAY OF HEMOSIDERIN No

QUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 194 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83080 ASSAY OF B No
HEXOSAMINIDASE

83088 ASSAY OF HISTAMINE No

83090 ASSAY OF HOMOCYSTINE No

83150 ASSAY OF No
HOMOVANILLIC ACID

83491 ASSAY OF No
CORTICOSTEROIDS 17

83497 ASSAY OF 5-HIAA No

83498 ASSAY OF No
PROGESTERONE 17-D

83499 ASSAY OF No
PROGESTERONE 20-

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 195 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83500 ASSAY FREE No

HYDROXYPROLINE

83505 ASSAY TOTAL No

HYDROXYPROLINE

83516 IMMUNOASSAY No
NONANTIBODY

83518 IMMUNOASSAY DIPSTICK No

83519 RIA NONANTIBODY No

83520 IMMUNOASSAY QUANT No

NOS NONAB

83525 ASSAY OF INSULIN No

83527 ASSAY OF INSULIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 196 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83528 ASSAY OF INTRINSIC No

FACTOR

83540 ASSAY OF IRON No

83550 IRON BINDING TEST No

83570 ASSAY OF IDH ENZYME No

83582 ASSAY OF KETOGENIC No

STEROIDS

83586 ASSAY 17- KETOSTEROIDS No

83593 FRACTIONATION No
KETOSTEROIDS

83605 ASSAY OF LACTIC ACID No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 197 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83615 LACTATE (LD) (LDH) No

ENZYME

83625 ASSAY OF LDH ENZYMES No

83630 LACTOFERRIN FECAL No

(QUAL)

83631 LACTOFERRIN FECAL No

(QUANT)

83632 PLACENTAL LACTOGEN No

83633 TEST URINE FOR LACTOSE No

83655 ASSAY OF LEAD No

83661 L/S RATIO FETAL LUNG No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 198 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83662 FOAM STABILITY FETAL No

LUNG

83663 FLUORO POLARIZE FETAL No

LUNG

83664 LAMELLAR BDY FETAL No

LUNG

83670 ASSAY OF LAP ENZYME No

83690 ASSAY OF LIPASE No

83695 ASSAY OF No
LIPOPROTEIN(A)

83698 ASSAY LIPOPROTEIN PLA2 No

83700 LIPOPRO BLD No

ELECTROPHORETIC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 199 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83701 LIPOPROTEIN BLD HR No

FRACTION

83704 LIPOPROTEIN BLD QUAN No

PART

83718 ASSAY OF LIPOPROTEIN No

83719 ASSAY OF BLOOD No

LIPOPROTEIN

83721 ASSAY OF BLOOD No

LIPOPROTEIN

83727 ASSAY OF LRH HORMONE No

83735 ASSAY OF MAGNESIUM No

83775 ASSAY MALATE No

DEHYDROGENASE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 200 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83785 ASSAY OF MANGANESE No

83789 MASS SPECTROMETRY No

QUAL/QUAN

83825 ASSAY OF MERCURY No

83835 ASSAY OF No
METANEPHRINES

83857 ASSAY OF No
METHEMALBUMIN

83861 MICROFLUID ANALY No

TEARS

83864 MUCOPOLYSACCHARIDES No

83872 ASSAY SYNOVIAL FLUID No

MUCIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 201 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83873 ASSAY OF CSF PROTEIN No

83874 ASSAY OF MYOGLOBIN No

83876 ASSAY No
MYELOPEROXIDASE

83880 ASSAY OF NATRIURETIC No

PEPTIDE

83883 ASSAY NEPHELOMETRY No

NOT SPEC

83885 ASSAY OF NICKEL No

83915 ASSAY OF NUCLEOTIDASE No

83916 OLIGOCLONAL BANDS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 202 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83918 ORGANIC ACIDS TOTAL No

QUANT

83919 ORGANIC ACIDS QUAL No

EACH

83921 ORGANIC ACID SINGLE No

QUANT

83930 ASSAY OF BLOOD No

OSMOLALITY

83935 ASSAY OF URINE No

OSMOLALITY

83937 ASSAY OF OSTEOCALCIN No

83945 ASSAY OF OXALATE No

83950 ONCOPROTEIN HER- No

2/NEU

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 203 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

83951 ONCOPROTEIN DCP No

83970 ASSAY OF No
PARATHORMONE

83986 ASSAY PH BODY FLUID No

NOS

83987 EXHALED BREATH No

CONDENSATE

83992 ASSAY FOR No

PHENCYCLIDINE

83993 ASSAY FOR No

CALPROTECTIN FECAL

84030 ASSAY OF BLOOD PKU No

84035 ASSAY OF No
PHENYLKETONES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 204 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84060 ASSAY ACID No

PHOSPHATASE

84061 PHOSPHATASE FORENSIC No

EXAM

84066 ASSAY PROSTATE No

PHOSPHATASE

84075 ASSAY ALKALINE No

PHOSPHATASE

84078 ASSAY ALKALINE No

PHOSPHATASE

84080 ASSAY ALKALINE No

PHOSPHATASES

84081 ASSAY No
PHOSPHATIDYLGLYCEROL

84085 ASSAY OF RBC PG6D No

ENZYME

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 205 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84087 ASSAY PHOSPHOHEXOSE No

ENZYMES

84100 ASSAY OF PHOSPHORUS No

84105 ASSAY OF URINE No

PHOSPHORUS

84106 TEST FOR No

PORPHOBILINOGEN

84110 ASSAY OF No
PORPHOBILINOGEN

84112 EVAL AMNIOTIC FLUID No

PROTEIN

84119 TEST URINE FOR No

PORPHYRINS

84120 ASSAY OF URINE No

PORPHYRINS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 206 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84126 ASSAY OF FECES No

PORPHYRINS

84132 ASSAY OF SERUM No

POTASSIUM

84133 ASSAY OF URINE No

POTASSIUM

84134 ASSAY OF PREALBUMIN No

84135 ASSAY OF PREGNANEDIOL No

84138 ASSAY OF No
PREGNANETRIOL

84140 ASSAY OF No
PREGNENOLONE

84143 ASSAY OF 17- No

HYDROXYPREGNENO

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 207 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84144 ASSAY OF No
PROGESTERONE

84145 PROCALCITONIN (PCT) No

84146 ASSAY OF PROLACTIN No

84150 ASSAY OF No
PROSTAGLANDIN

84152 ASSAY OF PSA No

COMPLEXED

84153 ASSAY OF PSA TOTAL No

84154 ASSAY OF PSA FREE No

84155 ASSAY OF PROTEIN No

SERUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 208 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84156 ASSAY OF PROTEIN URINE No

84157 ASSAY OF PROTEIN No

OTHER

84160 ASSAY OF PROTEIN ANY No

SOURCE

84163 PAPPA SERUM No

84165 PROTEIN E-PHORESIS No

SERUM

84166 PROTEIN E- No
PHORESIS/URINE/CSF

84181 WESTERN BLOT TEST No

84182 PROTEIN WESTERN BLOT No

TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 209 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84202 ASSAY RBC No

PROTOPORPHYRIN

84203 TEST RBC No

PROTOPORPHYRIN

84206 ASSAY OF PROINSULIN No

84207 ASSAY OF VITAMIN B-6 No

84210 ASSAY OF PYRUVATE No

84220 ASSAY OF PYRUVATE No

KINASE

84228 ASSAY OF QUININE No

84233 ASSAY OF ESTROGEN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 210 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84234 ASSAY OF No
PROGESTERONE

84235 ASSAY OF ENDOCRINE No

HORMONE

84238 ASSAY NONENDOCRINE No

RECEPTOR

84244 ASSAY OF RENIN No

84252 ASSAY OF VITAMIN B-2 No

84255 ASSAY OF SELENIUM No

84260 ASSAY OF SEROTONIN No

84270 ASSAY OF SEX HORMONE No

GLOBUL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 211 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84275 ASSAY OF SIALIC ACID No

84285 ASSAY OF SILICA No

84295 ASSAY OF SERUM No

SODIUM

84300 ASSAY OF URINE SODIUM No

84302 ASSAY OF SWEAT SODIUM No

84305 ASSAY OF SOMATOMEDIN No

84307 ASSAY OF SOMATOSTATIN No

84311 SPECTROPHOTOMETRY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 212 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84315 BODY FLUID SPECIFIC No

GRAVITY

84375 CHROMATOGRAM ASSAY No

SUGARS

84376 SUGARS SINGLE QUAL No

84377 SUGARS MULTIPLE QUAL No

84378 SUGARS SINGLE QUANT No

84379 SUGARS MULTIPLE No

QUANT

84392 ASSAY OF URINE SULFATE No

84402 ASSAY OF FREE No

TESTOSTERONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 213 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84403 ASSAY OF TOTAL No

TESTOSTERONE

84425 ASSAY OF VITAMIN B-1 No

84430 ASSAY OF THIOCYANATE No

84431 THROMBOXANE URINE No

84432 ASSAY OF No
THYROGLOBULIN

84436 ASSAY OF TOTAL No

THYROXINE

84437 ASSAY OF NEONATAL No

THYROXINE

84439 ASSAY OF FREE No

THYROXINE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 214 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84442 ASSAY OF THYROID No

ACTIVITY

84443 ASSAY THYROID STIM No

HORMONE

84445 ASSAY OF TSI GLOBULIN No

84446 ASSAY OF VITAMIN E No

84449 ASSAY OF TRANSCORTIN No

84450 TRANSFERASE (AST) No

(SGOT)

84460 ALANINE AMINO (ALT) No

(SGPT)

84466 ASSAY OF TRANSFERRIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 215 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84478 ASSAY OF TRIGLYCERIDES No

84479 ASSAY OF THYROID (T3 No

OR T4)

84480 ASSAY No
TRIIODOTHYRONINE (T3)

84481 FREE ASSAY (FT-3) No

84482 T3 REVERSE No

84484 ASSAY OF TROPONIN No

QUANT

84485 ASSAY DUODENAL FLUID No

TRYPSIN

84488 TEST FECES FOR TRYPSIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 216 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84490 ASSAY OF FECES FOR No

TRYPSIN

84510 ASSAY OF TYROSINE No

84512 ASSAY OF TROPONIN No

QUAL

84520 ASSAY OF UREA No

NITROGEN

84525 UREA NITROGEN SEMI- No

QUANT

84540 ASSAY OF URINE/UREA-N No

84545 UREA-N CLEARANCE TEST No

84550 ASSAY OF BLOOD/URIC No

ACID

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 217 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84560 ASSAY OF URINE/URIC No

ACID

84577 ASSAY OF No
FECES/UROBILINOGEN

84578 TEST URINE No

UROBILINOGEN

84580 ASSAY OF URINE No

UROBILINOGEN

84583 ASSAY OF URINE No

UROBILINOGEN

84585 ASSAY OF URINE VMA No

84586 ASSAY OF VIP No

84588 ASSAY OF VASOPRESSIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 218 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84590 ASSAY OF VITAMIN A No

84591 ASSAY OF NOS VITAMIN No

84597 ASSAY OF VITAMIN K No

84600 ASSAY OF VOLATILES No

84620 XYLOSE TOLERANCE TEST No

84630 ASSAY OF ZINC No

84681 ASSAY OF C-PEPTIDE No

84702 CHORIONIC No
GONADOTROPIN TEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 219 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

84703 CHORIONIC No
GONADOTROPIN ASSAY

84704 HCG FREE BETACHAIN No

TEST

84830 OVULATION TESTS No

84999 CLINICAL CHEMISTRY No

TEST

consultations (clinical pathology)

80500 LAB PATHOLOGY No
CONSULTATION

80502 LAB PATHOLOGY No

CONSULTATION

cytogenetic studies
88230 TISSUE CULTURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LYMPHOCYTE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 220 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88233 TISSUE CULTURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SKIN/BIOPSY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88235 TISSUE CULTURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PLACENTA more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88237 TISSUE CULTURE BONE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
MARROW more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88239 TISSUE CULTURE TUMOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88240 CELL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
CRYOPRESERVE/STORAGE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88241 FROZEN CELL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PREPARATION more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88245 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
20-25 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88248 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
50-100 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 221 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88248 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
50-100 more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

88249 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
100 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88261 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
5 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88262 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
15-20 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88263 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
45 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88264 CHROMOSOME ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
20-25 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88267 CHROMOSOME ANALYS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PLACENTA more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88269 CHROMOSOME ANALYS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
AMNIOTIC more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 222 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88271 CYTOGENETICS DNA Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PROBE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88272 CYTOGENETICS 3-5 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88273 CYTOGENETICS 10-30 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88274 CYTOGENETICS 25-99 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88275 CYTOGENETICS 100-300 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88280 CHROMOSOME Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
KARYOTYPE STUDY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88283 CHROMOSOME BANDING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
STUDY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88285 CHROMOSOME COUNT Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ADDITIONAL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 223 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88289 CHROMOSOME STUDY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ADDITIONAL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88291 CYTO/MOLECULAR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
REPORT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

88299 CYTOGENETIC STUDY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

cytopathology
88104 CYTOPATH FL NONGYN No
SMEARS

88106 CYTOPATH FL NONGYN No

FILTER

88108 CYTOPATH No
CONCENTRATE TECH

88112 CYTOPATH CELL No

ENHANCE TECH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 224 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88120 CYTP URNE 3-5 PROBES No

EA SPEC

88121 CYTP URINE 3-5 PROBES No

CMPTR

88125 FORENSIC No
CYTOPATHOLOGY

88130 SEX CHROMATIN No

IDENTIFICATION

88140 SEX CHROMATIN No

IDENTIFICATION

88141 CYTOPATH C/V No

INTERPRET

88142 CYTOPATH C/V THIN No

LAYER

88143 CYTOPATH C/V THIN No

LAYER REDO

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 225 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88147 CYTOPATH C/V No

AUTOMATED

88148 CYTOPATH C/V AUTO No

RESCREEN

88150 CYTOPATH C/V MANUAL No

88152 CYTOPATH C/V AUTO No

REDO

88153 CYTOPATH C/V REDO No

88154 CYTOPATH C/V SELECT No

88155 CYTOPATH C/V INDEX No

ADD-ON

88160 CYTOPATH SMEAR No

OTHER SOURCE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 226 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88161 CYTOPATH SMEAR No

OTHER SOURCE

88162 CYTOPATH SMEAR No

OTHER SOURCE

88164 CYTOPATH TBS C/V No

MANUAL

88165 CYTOPATH TBS C/V REDO No

88166 CYTOPATH TBS C/V AUTO No

REDO

88167 CYTOPATH TBS C/V No

SELECT

88172 CYTP DX EVAL FNA 1ST No

EA SITE

88173 CYTOPATH EVAL FNA No

REPORT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 227 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88174 CYTOPATH C/V AUTO IN No

FLUID

88175 CYTOPATH C/V AUTO No

FLUID REDO

88177 CYTP FNA EVAL EA ADDL No

88182 CELL MARKER STUDY No

88184 FLOWCYTOMETRY/ TC 1 No
MARKER

88185 FLOWCYTOMETRY/TC No
ADD-ON

88187 FLOWCYTOMETRY/READ No
2-8

88188 FLOWCYTOMETRY/READ No
9-15

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 228 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88189 FLOWCYTOMETRY/READ No
16 & >

88199 CYTOPATHOLOGY No
PROCEDURE

drug assay
80300 DRUG SCREEN NON TLC No
DEVICES

80301 DRUG SCREEN CLASS LIST No

A

80302 DRUG SCREEN PRSMPTV No

1 CLASS

80303 DRUG SCREEN No

ONE/MULT CLASS

80304 DRUG SCREEN No

ONE/MULT CLASS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 229 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80305 DRUG TEST PRSMV DIR No Please review the Well Sense Policy for Drug Screening Testing for Drugs of
OPT OBS more details Abuse and/or Controlled Substances

80306 DRUG TEST PRSMV No Please review the Well Sense Policy for Drug Screening Testing for Drugs of
INSTRMNT more details Abuse and/or Controlled Substances

80307 DRUG TEST PRSMV CHEM No Please review the Well Sense Policy for Drug Screening Testing for Drugs of
ANLYZR more details Abuse and/or Controlled Substances

80320 DRUG SCREEN No

QUANTALCOHOLS

80321 ALCOHOLS BIOMARKERS No

1OR 2

80322 ALCOHOLS BIOMARKERS No

3/MORE

80323 ALKALOIDS NOS No

80324 DRUG SCREEN No

AMPHETAMINES 1/2

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 230 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80325 AMPHETAMINES 3OR 4 No

80326 AMPHETAMINES 5 OR No
MORE

80327 ANABOLIC STEROID 1 OR No

2

80328 ANABOLIC STEROID 3 OR No

MORE

80329 ANALGESICS NON-OPIOID No

1 OR 2

80330 ANALGESICS NON-OPIOID No

3-5

80331 ANALGESICS NON-OPIOID No

6/MORE

80332 ANTIDEPRESSANTS CLASS No

1 OR 2

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 231 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80333 ANTIDEPRESSANTS CLASS No

3-5

80334 ANTIDEPRESSANTS CLASS No

6/MORE

80335 ANTIDEPRESSANT No
TRICYCLIC 1/2

80336 ANTIDEPRESSANT No
TRICYCLIC 3-5

80337 TRICYCLIC & CYCLICALS No

6/MORE

80338 ANTIDEPRESSANT NOT No

SPECIFIED

80339 ANTIEPILEPTICS NOS 1-3 No

80340 ANTIEPILEPTICS NOS 4-6 No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 232 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80341 ANTIEPILEPTICS NOS No

7/MORE

80342 ANTIPSYCHOTICS NOS 1-3 No

80343 ANTIPSYCHOTICS NOS 4-6 No

80344 ANTIPSYCHOTICS NOS No

7/MORE

80345 DRUG SCREENING No

BARBITURATES

80346 BENZODIAZEPINES1-12 No

80347 BENZODIAZEPINES 13 OR No
MORE

80348 DRUG SCREENING No

BUPRENORPHINE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 233 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80349 CANNABINOIDS NATURAL No

80350 CANNABINOIDS No
SYNTHETIC 1-3

80351 CANNABINOIDS No
SYNTHETIC 4-6

80352 CANNABINOID No
SYNTHETIC 7/MORE

80353 DRUG SCREENING No

COCAINE

80354 DRUG SCREENING No

FENTANYL

80355 GABAPENTIN NON-BLOOD No

80356 HEROIN METABOLITE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 234 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80357 KETAMINE AND No

NORKETAMINE

80358 DRUG SCREENING No

METHADONE

80359 METHYLENEDIOXYAMPHE No
TAMINES

80360 METHYLPHENIDATE No

80361 OPIATES 1 OR MORE No

80362 OPIOIDS & OPIATE No

ANALOGS 1/2

80363 OPIOIDS & OPIATE No

ANALOGS 3/4

80364 OPIOID &OPIATE No

ANALOG 5/MORE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 235 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80365 DRUG SCREENING No

OXYCODONE

80366 DRUG SCREENING No

PREGABALIN

80367 DRUG SCREENING No

PROPOXYPHENE

80368 SEDATIVE HYPNOTICS No

80369 SKELETAL MUSCLE No

RELAXANT 1/2

80370 SKEL MUSC RELAXANT 3 No

OR MORE

80371 STIMULANTS SYNTHETIC No

80372 DRUG SCREENING No

TAPENTADOL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 236 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80373 DRUG SCREENING No

TRAMADOL

80374 STEREOISOMER ANALYSIS No

80375 DRUG/SUBSTANCE NOS 1- No

3

80376 DRUG/SUBSTANCE NOS 4- No

6

80377 DRUG/SUBSTANCE NOS No

7/MORE

evocative/suppression testing
80400 ACTH STIMULATION No
PANEL

80402 ACTH STIMULATION No

PANEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 237 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80406 ACTH STIMULATION No

PANEL

80408 ALDOSTERONE No
SUPPRESSION EVAL

80410 CALCITONIN STIMUL No

PANEL

80412 CRH STIMULATION PANEL No

80414 TESTOSTERONE No
RESPONSE

80415 ESTRADIOL RESPONSE No

PANEL

80416 RENIN STIMULATION No

PANEL

80417 RENIN STIMULATION No

PANEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 238 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80418 PITUITARY EVALUATION No

PANEL

80420 DEXAMETHASONE PANEL No

80422 GLUCAGON TOLERANCE No

PANEL

80424 GLUCAGON TOLERANCE No

PANEL

80426 GONADOTROPIN No
HORMONE PANEL

80428 GROWTH HORMONE No

PANEL

80430 GROWTH HORMONE No

PANEL

80432 INSULIN SUPPRESSION No

PANEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 239 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80434 INSULIN TOLERANCE No

PANEL

80435 INSULIN TOLERANCE No

PANEL

80436 METYRAPONE PANEL No

80438 TRH STIMULATION PANEL No

80439 TRH STIMULATION PANEL No

Genomic Sequencing Procedures and Other Molecular Multianalyte Assays

81410 AORTIC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DYSFUNCTION/DILATION more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81411 AORTIC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DYSFUNCTION/DILATION more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 240 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81412 ASHKENAZI JEWISH Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ASSOC DIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81413 CAR ION CHNNLPATH INC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
10 GNS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81414 CAR ION CHNNLPATH INC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
2 GNS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81415 EXOME SEQUENCE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYSIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81416 EXOME SEQUENCE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYSIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81417 EXOME RE-EVALUATION Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81420 FETAL CHRMOML Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANEUPLOIDY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81422 FETAL CHRMOML Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
MICRODELTJ more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 241 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81425 GENOME SEQUENCE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYSIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81426 GENOME SEQUENCE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYSIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81427 GENOME RE-EVALUATION Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81430 HEARING LOSS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE ANALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81431 HEARING LOSS DUP/DEL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81432 HRDTRY BRST CA-RLATD Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
DSORDRS more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81433 HRDTRY BRST CA-RLATD Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
DSORDRS more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81434 HEREDITARY RETINAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DISORDERS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 242 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81435 HEREDITARY COLON CA Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
DSORDRS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81436 HEREDITARY COLON CA Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
DSORDRS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81437 HEREDTRY NURONDCRN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
TUM DSRDR more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81438 HEREDTRY NURONDCRN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
TUM DSRDR more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81439 INHERITED CARDMYPTHY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
5 GNS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81440 MITOCHONDRIAL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81442 NOONAN SPECTRUM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DISORDERS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81443 GENETIC TSTG SEVERE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
INH COND more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 243 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81445 TARGETED GENOMIC SEQ Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81448 HRDTRY PERPH NEURPHY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PANEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81450 TARGETED GENOMIC SEQ Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81455 TARGETED GENOMIC SEQ Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81460 WHOLE MITOCHONDRIAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
GENOME more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81465 WHOLE MITOCHONDRIAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
GENOME more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81470 X-LINKED INTELLECTUAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DBLT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81471 X-LINKED INTELLECTUAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DBLT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 244 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81479 UNLISTED MOLECULAR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PATHOLOGY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

hematology and coagulation

85002 BLEEDING TIME TEST No

85004 AUTOMATED DIFF WBC No

COUNT

85007 BL SMEAR W/DIFF WBC No

COUNT

85008 BL SMEAR W/O DIFF WBC No

COUNT

85009 MANUAL DIFF WBC No

COUNT B-COAT

85013 SPUN No
MICROHEMATOCRIT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 245 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85014 HEMATOCRIT No

85018 HEMOGLOBIN No

85025 COMPLETE CBC W/AUTO No

DIFF WBC

85027 COMPLETE CBC No

AUTOMATED

85032 MANUAL CELL COUNT No

EACH

85041 AUTOMATED RBC COUNT No

85044 MANUAL RETICULOCYTE No

COUNT

85045 AUTOMATED No
RETICULOCYTE COUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 246 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85046 RETICYTE/HGB No
CONCENTRATE

85048 AUTOMATED LEUKOCYTE No

COUNT

85049 AUTOMATED PLATELET No

COUNT

85055 RETICULATED PLATELET No

ASSAY

85060 BLOOD SMEAR No

INTERPRETATION

85097 BONE MARROW No

INTERPRETATION

85130 CHROMOGENIC No
SUBSTRATE ASSAY

85170 BLOOD CLOT RETRACTION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 247 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85175 BLOOD CLOT LYSIS TIME No

85210 CLOT FACTOR II No

PROTHROM SPEC

85220 BLOOC CLOT FACTOR V No

TEST

85230 CLOT FACTOR VII No

PROCONVERTIN

85240 CLOT FACTOR VIII AHG 1 No

STAGE

85244 CLOT FACTOR VIII RELTD No

ANTGN

85245 CLOT FACTOR VIII VW No

RISTOCTN

85246 CLOT FACTOR VIII VW No

ANTIGEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 248 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85247 CLOT FACTOR VIII No

MULTIMETRIC

85250 CLOT FACTOR IX No

PTC/CHRSTMAS

85260 CLOT FACTOR X STUART- No

POWER

85270 CLOT FACTOR XI PTA No

85280 CLOT FACTOR XII No

HAGEMAN

85290 CLOT FACTOR XIII FIBRIN No

STAB

85291 CLOT FACTOR XIII FIBRIN No

SCRN

85292 CLOT FACTOR FLETCHER No

FACT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 249 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85293 CLOT FACTOR WGHT No

KININOGEN

85300 ANTITHROMBIN III No

ACTIVITY

85301 ANTITHROMBIN III No

ANTIGEN

85302 CLOT INHIBIT PROT C No

ANTIGEN

85303 CLOT INHIBIT PROT C No

ACTIVITY

85305 CLOT INHIBIT PROT S No

TOTAL

85306 CLOT INHIBIT PROT S No

FREE

85307 ASSAY ACTIVATED No

PROTEIN C

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 250 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85335 FACTOR INHIBITOR TEST No

85337 THROMBOMODULIN No

85345 COAGULATION TIME LEE No

& WHITE

85347 COAGULATION TIME No

ACTIVATED

85348 COAGULATION TIME OTR No

METHOD

85360 EUGLOBULIN LYSIS No

85362 FIBRIN DEGRADATION No

PRODUCTS

85366 FIBRINOGEN TEST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 251 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85370 FIBRINOGEN TEST No

85378 FIBRIN DEGRADE No

SEMIQUANT

85379 FIBRIN DEGRADATION No

QUANT

85380 FIBRIN DEGRADJ D-DIMER No

85384 FIBRINOGEN ACTIVITY No

85385 FIBRINOGEN ANTIGEN No

85390 FIBRINOLYSINS SCREEN No

I&R

85396 CLOTTING ASSAY WHOLE No

BLOOD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 252 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85397 CLOTTING FUNCT No

ACTIVITY

85400 FIBRINOLYTIC PLASMIN No

85410 FIBRINOLYTIC No
ANTIPLASMIN

85415 FIBRINOLYTIC No
PLASMINOGEN

85420 FIBRINOLYTIC No
PLASMINOGEN

85421 FIBRINOLYTIC No
PLASMINOGEN

85441 HEINZ BODIES DIRECT No

85445 HEINZ BODIES INDUCED No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 253 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85460 HEMOGLOBIN FETAL No

85461 HEMOGLOBIN FETAL No

85475 HEMOLYSIN ACID No

85520 HEPARIN ASSAY No

85525 HEPARIN No
NEUTRALIZATION

85530 HEPARIN-PROTAMINE No
TOLERANCE

85536 IRON STAIN PERIPHERAL No

BLOOD

85540 WBC ALKALINE No

PHOSPHATASE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 254 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85547 RBC MECHANICAL No

FRAGILITY

85549 MURAMIDASE No

85555 RBC OSMOTIC FRAGILITY No

85557 RBC OSMOTIC FRAGILITY No

85576 BLOOD PLATELET No

AGGREGATION

85597 PHOSPHOLIPID PLTLT No

NEUTRALIZ

85598 HEXAGNAL PHOSPH No

PLTLT NEUTRL

85610 PROTHROMBIN TIME No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 255 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85611 PROTHROMBIN TEST No

85612 VIPER VENOM No

PROTHROMBIN TIME

85613 RUSSELL VIPER VENOM No

DILUTED

85635 REPTILASE TEST No

85651 RBC SED RATE No

NONAUTOMATED

85652 RBC SED RATE No

AUTOMATED

85660 RBC SICKLE CELL TEST No

85670 THROMBIN TIME PLASMA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 256 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

85675 THROMBIN TIME TITER No

85705 THROMBOPLASTIN No
INHIBITION

85730 THROMBOPLASTIN TIME No

PARTIAL

85732 THROMBOPLASTIN TIME No

PARTIAL

85810 BLOOD VISCOSITY No

EXAMINATION

85999 HEMATOLOGY No
PROCEDURE

immunology
86000 AGGLUTININS FEBRILE No
ANTIGEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 257 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86001 ALLERGEN SPECIFIC IGG No

86003 ALLERGEN SPECIFIC IGE No

86005 ALLERGEN SPECIFIC IGE No

86021 WBC ANTIBODY No

IDENTIFICATION

86022 PLATELET ANTIBODIES No

86023 IMMUNOGLOBULIN No
ASSAY

86038 ANTINUCLEAR No
ANTIBODIES

86039 ANTINUCLEAR No
ANTIBODIES (ANA)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 258 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86060 ANTISTREPTOLYSIN O No
TITER

86063 ANTISTREPTOLYSIN O No
SCREEN

86077 PHYS BLOOD BANK SERV No

XMATCH

86078 PHYS BLOOD BANK SERV No

REACTJ

86079 PHYS BLOOD BANK SERV No

AUTHRJ

86140 C-REACTIVE PROTEIN No

86141 C-REACTIVE PROTEIN HS No

86146 BETA-2 GLYCOPROTEIN No

ANTIBODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 259 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86147 CARDIOLIPIN ANTIBODY No

EA IG

86148 ANTI-PHOSPHOLIPID No
ANTIBODY

86152 CELL ENUMERATION & ID No

86153 CELL ENUMERATION No

PHYS INTERP

86155 CHEMOTAXIS ASSAY No

86156 COLD AGGLUTININ No

SCREEN

86157 COLD AGGLUTININ TITER No

86160 COMPLEMENT ANTIGEN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 260 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86161 COMPLEMENT/FUNCTION No
ACTIVITY

86162 COMPLEMENT TOTAL No

(CH50)

86171 COMPLEMENT FIXATION No

EACH

86185 COUNTERIMMUNOELECT No
ROPHORESIS

86200 CCP ANTIBODY No

86215 DEOXYRIBONUCLEASE No
ANTIBODY

86225 DNA ANTIBODY NATIVE No

86226 DNA ANTIBODY SINGLE No

STRAND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 261 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86235 NUCLEAR ANTIGEN No

ANTIBODY

86243 FC RECEPTOR No

86255 FLUORESCENT ANTIBODY No

SCREEN

86256 FLUORESCENT ANTIBODY No

TITER

86277 GROWTH HORMONE No

ANTIBODY

86280 HEMAGGLUTINATION No
INHIBITION

86294 IMMUNOASSAY TUMOR No

QUAL

86300 IMMUNOASSAY TUMOR No

CA 15-3

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 262 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86301 IMMUNOASSAY TUMOR No

CA 19-9

86304 IMMUNOASSAY TUMOR No

CA 125

86305 HUMAN EPIDIDYMIS No

PROTEIN 4

86308 HETEROPHILE ANTIBODY No

SCREEN

86309 HETEROPHILE ANTIBODY No

TITER

86310 HETEROPHILE ANTIBODY No

ABSRBJ

86316 IMMUNOASSAY TUMOR No

OTHER

86317 IMMUNOASSAY No
INFECTIOUS AGENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 263 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86318 IMMUNOASSAY No
INFECTIOUS AGENT

86320 SERUM No
IMMUNOELECTROPHORE
SIS

86325 OTHER No
IMMUNOELECTROPHORE
SIS

86327 IMMUNOELECTROPHORE No
SIS ASSAY

86329 IMMUNODIFFUSION NES No

86331 IMMUNODIFFUSION No
OUCHTERLONY

86332 IMMUNE COMPLEX No

ASSAY

86334 IMMUNOFIX E-PHORESIS No

SERUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 264 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86335 IMMUNFIX E- No
PHORSIS/URINE/CSF

86336 INHIBIN A No

86337 INSULIN ANTIBODIES No

86340 INTRINSIC FACTOR No

ANTIBODY

86341 ISLET CELL ANTIBODY No

86343 LEUKOCYTE HISTAMINE No

RELEASE

86344 LEUKOCYTE No
PHAGOCYTOSIS

86352 CELL FUNCTION ASSAY No

W/STIM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 265 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86353 LYMPHOCYTE No
TRANSFORMATION

86355 B CELLS TOTAL COUNT No

86356 MONONUCLEAR CELL No

ANTIGEN

86357 NK CELLS TOTAL COUNT No

86359 T CELLS TOTAL COUNT No

86360 T CELL ABSOLUTE No

COUNT/RATIO

86361 T CELL ABSOLUTE COUNT No

86367 STEM CELLS TOTAL No

COUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 266 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86376 MICROSOMAL ANTIBODY No

EACH

86378 MIGRATION INHIBITORY No

FACTOR

86382 NEUTRALIZATION TEST No

VIRAL

86384 NITROBLUE No
TETRAZOLIUM DYE

86386 NUCLEAR MATRIX No

PROTEIN 22

86403 PARTICLE AGGLUT No

ANTBDY SCRN

86406 PARTICLE AGGLUT No

ANTBDY TITR

86430 RHEUMATOID FACTOR No

TEST QUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 267 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86431 RHEUMATOID FACTOR No

QUANT

86480 TB TEST CELL IMMUN No

MEASURE

86481 TB AG RESPONSE T-CELL No

SUSP

86485 SKIN TEST CANDIDA No

86486 SKIN TEST NOS ANTIGEN No

86490 COCCIDIOIDOMYCOSIS No
SKIN TEST

86510 HISTOPLASMOSIS SKIN No

TEST

86580 TB INTRADERMAL TEST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 268 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86590 STREPTOKINASE No
ANTIBODY

86592 SYPHILIS TEST NON-TREP No

QUAL

86593 SYPHILIS TEST NON-TREP No

QUANT

86602 ANTINOMYCES ANTIBODY No

86603 ADENOVIRUS ANTIBODY No

86606 ASPERGILLUS ANTIBODY No

86609 BACTERIUM ANTIBODY No

86611 BARTONELLA ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 269 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86612 BLASTOMYCES ANTIBODY No

86615 BORDETELLA ANTIBODY No

86617 LYME DISEASE ANTIBODY No

86618 LYME DISEASE ANTIBODY No

86619 BORRELIA ANTIBODY No

86622 BRUCELLA ANTIBODY No

86625 CAMPYLOBACTER No
ANTIBODY

86628 CANDIDA ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 270 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86631 CHLAMYDIA ANTIBODY No

86632 CHLAMYDIA IGM No

ANTIBODY

86635 COCCIDIOIDES ANTIBODY No

86638 Q FEVER ANTIBODY No

86641 CRYPTOCOCCUS No
ANTIBODY

86644 CMV ANTIBODY No

86645 CMV ANTIBODY IGM No

86648 DIPHTHERIA ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 271 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86651 ENCEPHALITIS CALIFORN No

ANTBDY

86652 ENCEPHALTIS EAST EQNE No

ANBDY

86653 ENCEPHALTIS ST LOUIS No

ANTBODY

86654 ENCEPHALTIS WEST No

EQNE ANTBDY

86658 ENTEROVIRUS ANTIBODY No

86663 EPSTEIN-BARR ANTIBODY No

86664 EPSTEIN-BARR NUCLEAR No

ANTIGEN

86665 EPSTEIN-BARR CAPSID No

VCA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 272 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86666 EHRLICHIA ANTIBODY No

86668 FRANCISELLA TULARENSIS No

86671 FUNGUS NES ANTIBODY No

86674 GIARDIA LAMBLIA No

ANTIBODY

86677 HELICOBACTER PYLORI No

ANTIBODY

86682 HELMINTH ANTIBODY No

86684 HEMOPHILUS INFLUENZA No

ANTIBDY

86687 HTLV-I ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 273 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86688 HTLV-II ANTIBODY No

86689 HTLV/HIV CONFIRMJ No

ANTIBODY

86692 HEPATITIS DELTA AGENT No

ANTBDY

86694 HERPES SIMPLEX NES No

ANTBDY

86695 HERPES SIMPLEX TYPE 1 No

TEST

86696 HERPES SIMPLEX TYPE 2 No

TEST

86698 HISTOPLASMA ANTIBODY No

86701 HIV-1ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 274 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86702 HIV-2 ANTIBODY No

86703 HIV-1/HIV-2 1 RESULT No

ANTBDY

86704 HEP B CORE ANTIBODY No

TOTAL

86705 HEP B CORE ANTIBODY No

IGM

86706 HEP B SURFACE No

ANTIBODY

86707 HEPATITIS BE ANTIBODY No

86708 HEPATITIS A ANTIBODY No

86709 HEPATITIS A IGM No

ANTIBODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 275 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86710 INFLUENZA VIRUS No

ANTIBODY

86711 JOHN CUNNINGHAM No

ANTIBODY

86713 LEGIONELLA ANTIBODY No

86717 LEISHMANIA ANTIBODY No

86720 LEPTOSPIRA ANTIBODY No

86723 LISTERIA No
MONOCYTOGENES

86727 LYMPH No
CHORIOMENINGITIS AB

86729 LYMPHO VENEREUM No

ANTIBODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 276 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86732 MUCORMYCOSIS No
ANTIBODY

86735 MUMPS ANTIBODY No

86738 MYCOPLASMA ANTIBODY No

86741 NEISSERIA MENINGITIDIS No

86744 NOCARDIA ANTIBODY No

86747 PARVOVIRUS ANTIBODY No

86750 MALARIA ANTIBODY No

86753 PROTOZOA ANTIBODY No

NOS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 277 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86756 RESPIRATORY VIRUS No

ANTIBODY

86757 RICKETTSIA ANTIBODY No

86759 ROTAVIRUS ANTIBODY No

86762 RUBELLA ANTIBODY No

86765 RUBEOLA ANTIBODY No

86768 SALMONELLA ANTIBODY No

86771 SHIGELLA ANTIBODY No

86774 TETANUS ANTIBODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 278 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86777 TOXOPLASMA ANTIBODY No

86778 TOXOPLASMA ANTIBODY No

IGM

86780 TREPONEMA PALLIDUM No

86784 TRICHINELLA ANTIBODY No

86787 VARICELLA-ZOSTER No
ANTIBODY

86788 WEST NILE VIRUS AB IGM No

86789 WEST NILE VIRUS No

ANTIBODY

86790 VIRUS ANTIBODY NOS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 279 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86793 YERSINIA ANTIBODY No

86800 THYROGLOBULIN No
ANTIBODY

86803 HEPATITIS C AB TEST No

86804 HEP C AB TEST CONFIRM No

86805 LYMPHOCYTOTOXICITY No
ASSAY

86806 LYMPHOCYTOTOXICITY No
ASSAY

86807 CYTOTOXIC ANTIBODY No

SCREENING

86808 CYTOTOXIC ANTIBODY No

SCREENING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 280 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86812 HLA TYPING A B OR C No

86813 HLA TYPING A B OR C No

86816 HLA TYPING DR/DQ No

86817 HLA TYPING DR/DQ No

86821 LYMPHOCYTE CULTURE No

MIXED

86822 LYMPHOCYTE CULTURE No

PRIMED

86825 HLA X-MATH NON- No

CYTOTOXIC

86826 HLA X-MATCH No

NONCYTOTOXC ADDL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 281 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86828 HLA CLASS I&II ANTIBODY No

QUAL

86829 HLA CLASS I/II ANTIBODY No

QUAL

86830 HLA CLASS I PHENOTYPE No

QUAL

86831 HLA CLASS II PHENOTYPE No

QUAL

86832 HLA CLASS I HIGH DEFIN No

QUAL

86833 HLA CLASS II HIGH DEFIN No

QUAL

86834 HLA CLASS I SEMIQUANT No

PANEL

86835 HLA CLASS II SEMIQUANT No

PANEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 282 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86849 IMMUNOLOGY No
PROCEDURE

in vivo (transcutaneous) lab procedures

88720 BILIRUBIN TOTAL No
TRANSCUT

88738 HGB QUANT No

TRANSCUTANEOUS

88740 TRANSCUTANEOUS No
CARBOXYHB

88741 TRANSCUTANEOUS No
METHB

microbiology
87003 SMALL ANIMAL No
INOCULATION

87015 SPECIMEN INFECT AGNT No

CONCNTJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 283 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87040 BLOOD CULTURE FOR No

BACTERIA

87045 FECES CULTURE AEROBIC No

BACT

87046 STOOL CULTR AEROBIC No

BACT EA

87070 CULTURE OTHR SPECIMN No

AEROBIC

87071 CULTURE AEROBIC No

QUANT OTHER

87073 CULTURE BACTERIA No

ANAEROBIC

87075 CULTR BACTERIA EXCEPT No

BLOOD

87076 CULTURE ANAEROBE No

IDENT EACH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 284 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87077 CULTURE AEROBIC No

IDENTIFY

87081 CULTURE SCREEN ONLY No

87084 CULTURE OF SPECIMEN No

BY KIT

87086 URINE CULTURE/COLONY No

COUNT

87088 URINE BACTERIA No

CULTURE

87101 SKIN FUNGI CULTURE No

87102 FUNGUS ISOLATION No

CULTURE

87103 BLOOD FUNGUS CULTURE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 285 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87106 FUNGI IDENTIFICATION No

YEAST

87107 FUNGI IDENTIFICATION No

MOLD

87109 MYCOPLASMA No

87110 CHLAMYDIA CULTURE No

87116 MYCOBACTERIA CULTURE No

87118 MYCOBACTERIC No
IDENTIFICATION

87140 CULTURE TYPE No

IMMUNOFLUORESC

87143 CULTURE TYPING No

GLC/HPLC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 286 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87147 CULTURE TYPE No

IMMUNOLOGIC

87149 DNA/RNA DIRECT PROBE No

87150 DNA/RNA AMPLIFIED No

PROBE

87152 CULTURE TYPE PULSE No

FIELD GEL

87153 DNA/RNA SEQUENCING No

87158 CULTURE TYPING ADDED No

METHOD

87164 DARK FIELD No

EXAMINATION

87166 DARK FIELD No

EXAMINATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 287 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87168 MACROSCOPIC EXAM No

ARTHROPOD

87169 MACROSCOPIC EXAM No

PARASITE

87172 PINWORM EXAM No

87176 TISSUE No
HOMOGENIZATION
CULTR

87177 OVA AND PARASITES No

SMEARS

87181 MICROBE SUSCEPTIBLE No

DIFFUSE

87184 MICROBE SUSCEPTIBLE No

DISK

87185 MICROBE SUSCEPTIBLE No

ENZYME

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 288 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87186 MICROBE SUSCEPTIBLE No

MIC

87187 MICROBE SUSCEPTIBLE No

MLC

87188 MICROBE SUSCEPT No

MACROBROTH

87190 MICROBE SUSCEPT No

MYCOBACTERI

87197 BACTERICIDAL LEVEL No

SERUM

87205 SMEAR GRAM STAIN No

87206 SMEAR No
FLUORESCENT/ACID STAI

87207 SMEAR SPECIAL STAIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 289 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87209 SMEAR COMPLEX STAIN No

87210 SMEAR WET MOUNT No

SALINE/INK

87220 TISSUE EXAM FOR FUNGI No

87230 ASSAY TOXIN OR No

ANTITOXIN

87250 VIRUS INOCULATE No

EGGS/ANIMAL

87252 VIRUS INOCULATION No

TISSUE

87253 VIRUS INOCULATE TISSUE No

ADDL

87254 VIRUS INOCULATION No

SHELL VIA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 290 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87255 GENET VIRUS ISOLATE No

HSV

87260 ADENOVIRUS AG IF No

87265 PERTUSSIS AG IF No

87267 ENTEROVIRUS ANTIBODY No

DFA

87269 GIARDIA AG IF No

87270 CHLAMYDIA No
TRACHOMATIS AG IF

87271 CYTOMEGALOVIRUS DFA No

87272 CRYPTOSPORIDIUM AG IF No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 291 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87273 HERPES SIMPLEX 2 AG IF No

87274 HERPES SIMPLEX 1 AG IF No

87275 INFLUENZA B AG IF No

87276 INFLUENZA A AG IF No

87277 LEGIONELLA MICDADEI No

AG IF

87278 LEGION PNEUMOPHILIA No

AG IF

87279 PARAINFLUENZA AG IF No

87280 RESPIRATORY SYNCYTIAL No

AG IF

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 292 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87281 PNEUMOCYSTIS CARINII No

AG IF

87283 RUBEOLA AG IF No

87285 TREPONEMA PALLIDUM No

AG IF

87290 VARICELLA ZOSTER AG IF No

87299 ANTIBODY DETECTION No

NOS IF

87300 AG DETECTION POLYVAL No

IF

87301 ADENOVIRUS AG IA No

87305 ASPERGILLUS AG IA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 293 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87320 CHYLMD TRACH AG IA No

87324 CLOSTRIDIUM AG IA No

87327 CRYPTOCOCCUS No
NEOFORM AG IA

87328 CRYPTOSPORIDIUM AG IA No

87329 GIARDIA AG IA No

87332 CYTOMEGALOVIRUS AG No
IA

87335 E COLI 0157 AG IA No

87336 ENTAMOEB HIST DISPR No

AG IA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 294 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87337 ENTAMOEB HIST GROUP No

AG IA

87338 HPYLORI STOOL IA No

87339 H PYLORI AG IA No

87340 HEPATITIS B SURFACE AG No

IA

87341 HEPATITIS B SURFACE AG No

IA

87350 HEPATITIS BE AG IA No

87380 HEPATITIS DELTA AG IA No

87385 HISTOPLASMA CAPSUL No

AG IA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 295 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87389 HIV-1 AG W/HIV-1 & HIV- No

2 AB

87390 HIV-1 AG IA No

87391 HIV-2 AG IA No

87400 INFLUENZA A/B AG IA No

87420 RESP SYNCYTIAL AG IA No

87425 ROTAVIRUS AG IA No

87427 SHIGA-LIKE TOXIN AG IA No

87430 STREP A AG IA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 296 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87449 AG DETECT NOS IA MULT No

87450 AG DETECT NOS IA SINGLE No

87451 AG DETECT POLYVAL IA No

MULT

87470 BARTONELLA DNA DIR No

PROBE

87471 BARTONELLA DNA AMP No

PROBE

87472 BARTONELLA DNA QUANT No

87475 LYME DIS DNA DIR PROBE No

87476 LYME DIS DNA AMP No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 297 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87477 LYME DIS DNA QUANT No

87480 CANDIDA DNA DIR PROBE No

87481 CANDIDA DNA AMP No

PROBE

87482 CANDIDA DNA QUANT No

87485 CHYLMD PNEUM DNA No

DIR PROBE

87486 CHYLMD PNEUM DNA No

AMP PROBE

87487 CHYLMD PNEUM DNA No

QUANT

87490 CHYLMD TRACH DNA DIR No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 298 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87491 CHYLMD TRACH DNA No

AMP PROBE

87492 CHYLMD TRACH DNA No

QUANT

87493 C DIFF AMPLIFIED PROBE No

87495 CYTOMEG DNA DIR No

PROBE

87496 CYTOMEG DNA AMP No

PROBE

87497 CYTOMEG DNA QUANT No

87498 ENTEROVIRUS No
PROBE&REVRS TRNS

87500 VANOMYCIN DNA AMP No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 299 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87501 INFLUENZA DNA AMP No

PROB 1+

87502 INFLUENZA DNA AMP No

PROBE

87503 INFLUENZA DNA AMP No

PROB ADDL

87505 NFCT AGENT DETECTION No

GI

87506 IADNA-DNA/RNA PROBE No

TQ 6-11

87507 IADNA-DNA/RNA PROBE No

TQ 12-25

87510 GARDNER VAG DNA DIR No

PROBE

87511 GARDNER VAG DNA AMP No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 300 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87512 GARDNER VAG DNA No

QUANT

87515 HEPATITIS B DNA DIR No

PROBE

87516 HEPATITIS B DNA AMP No

PROBE

87517 HEPATITIS B DNA QUANT No

87520 HEPATITIS C RNA DIR No

PROBE

87521 HEPATITIS C No
PROBE&RVRS TRNSC

87522 HEPATITIS C REVRS No

TRNSCRPJ

87525 HEPATITIS G DNA DIR No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 301 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87526 HEPATITIS G DNA AMP No

PROBE

87527 HEPATITIS G DNA QUANT No

87528 HSV DNA DIR PROBE No

87529 HSV DNA AMP PROBE No

87530 HSV DNA QUANT No

87531 HHV-6 DNA DIR PROBE No

87532 HHV-6 DNA AMP PROBE No

87533 HHV-6 DNA QUANT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 302 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87534 HIV-1 DNA DIR PROBE No

87535 HIV-1 PROBE&REVERSE No

TRNSCRPJ

87536 HIV-1 QUANT&REVRSE No

TRNSCRPJ

87537 HIV-2 DNA DIR PROBE No

87538 HIV-2 PROBE&REVRSE No

TRNSCRIPJ

87539 HIV-2 QUANT&REVRSE No

TRNSCRIPJ

87540 LEGION PNEUMO DNA No

DIR PROB

87541 LEGION PNEUMO DNA No

AMP PROB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 303 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87542 LEGION PNEUMO DNA No

QUANT

87550 MYCOBACTERIA DNA DIR No

PROBE

87551 MYCOBACTERIA DNA No

AMP PROBE

87552 MYCOBACTERIA DNA No

QUANT

87555 M.TUBERCULO DNA DIR No

PROBE

87556 M.TUBERCULO DNA AMP No

PROBE

87557 M.TUBERCULO DNA No

QUANT

87560 M.AVIUM-INTRA DNA DIR No

PROB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 304 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87561 M.AVIUM-INTRA DNA No

AMP PROB

87562 M.AVIUM-INTRA DNA No

QUANT

87580 M.PNEUMON DNA DIR No

PROBE

87581 M.PNEUMON DNA AMP No

PROBE

87582 M.PNEUMON DNA No

QUANT

87590 N.GONORRHOEAE DNA No

DIR PROB

87591 N.GONORRHOEAE DNA No

AMP PROB

87592 N.GONORRHOEAE DNA No

QUANT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 305 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87623 HPV LOW-RISK TYPES No

87624 HPV HIGH-RISK TYPES No

87625 HPV TYPES 16 & 18 ONLY No

87631 RESP VIRUS 3-5 TARGETS No

87632 RESP VIRUS 6-11 TARGETS No

87633 RESP VIRUS 12-25 No

TARGETS

87640 STAPH A DNA AMP PROBE No

87641 MR-STAPH DNA AMP No

PROBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 306 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87650 STREP A DNA DIR PROBE No

87651 STREP A DNA AMP PROBE No

87652 STREP A DNA QUANT No

87653 STREP B DNA AMP PROBE No

87660 TRICHOMONAS VAGIN No

DIR PROBE

87661 TRICHOMONAS No
VAGINALIS AMPLIF

87797 DETECT AGENT NOS DNA No

DIR

87798 DETECT AGENT NOS DNA No

AMP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 307 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87799 DETECT AGENT NOS DNA No

QUANT

87800 DETECT AGNT MULT DNA No

DIREC

87801 DETECT AGNT MULT DNA No

AMPLI

87802 STREP B ASSAY W/OPTIC No

87803 CLOSTRIDIUM TOXIN A No

W/OPTIC

87804 INFLUENZA ASSAY No

W/OPTIC

87806 HIV ANTIGEN W/HIV No

ANTIBODIES

87807 RSV ASSAY W/OPTIC No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 308 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87808 TRICHOMONAS ASSAY No

W/OPTIC

87809 ADENOVIRUS ASSAY No

W/OPTIC

87810 CHYLMD TRACH ASSAY No

W/OPTIC

87850 N. GONORRHOEAE ASSAY No

W/OPTIC

87880 STREP A ASSAY W/OPTIC No

87899 AGENT NOS ASSAY No

W/OPTIC

87900 PHENOTYPE INFECT No

AGENT DRUG

87901 GENOTYPE DNA HIV No

REVERSE T

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 309 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

87902 GENOTYPE DNA/RNA HEP No

C

87903 PHENOTYPE DNA HIV No

W/CULTURE

87904 PHENOTYPE DNA HIV No

W/CLT ADD

87905 SIALIDASE ENZYME ASSAY No

87906 GENOTYPE DNA/RNA HIV No

87910 GENOTYPE No
CYTOMEGALOVIRUS

87912 GENOTYPE DNA No

HEPATITIS B

87999 MICROBIOLOGY No
PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 310 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

Molecular Pathology
81105 HPA-1 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81106 HPA-2 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81107 HPA-3 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81108 HPA-4 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81109 HPA-5 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81110 HPA-6 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81111 HPA-9 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 311 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81112 HPA-15 GENOTYPING Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81120 IDH1 COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81121 IDH2 COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81161 DMD DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ANALYSIS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81162 BRCA1&2 SEQ & FULL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
DUP/DEL more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81163 BRCA1&2 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
ALYS more details and Ovarian Cancer Syndrome Hereditary Breast and
Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81164 BRCA1&2 GEN FUL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
DUP/DEL ALYS more details and Ovarian Cancer Syndrome Hereditary Breast and
Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81165 BRCA1 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
ALYS more details and Ovarian Cancer Syndrome Hereditary Breast and
Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 312 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81166 BRCA1 GENE FULL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
DUP/DEL ALYS more details and Ovarian Cancer Syndrome Hereditary Breast and
Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81167 BRCA2 GENE FULL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
DUP/DEL ALYS more details and Ovarian Cancer Syndrome Hereditary Breast and
Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81170 ABL1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81171 AFF2 GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
ALLELES more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81172 AFF2 GENE CHARAC Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
ALLELES more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81173 AR GENE FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81174 AR GENE KNOWN FAMIL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81175 ASXL1 FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 313 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81176 ASXL1 GENE TARGET SEQ Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
ALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81177 ATN1 GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81178 ATXN1 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81179 ATXN2 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81180 ATXN3 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81181 ATXN7 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81182 ATXN8OS GEN DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81183 ATXN10 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 314 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81184 CACNA1A GEN DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81185 CACNA1A GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
GENE SEQ more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81186 CACNA1A GEN KNOWN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
FAMIL VRNT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81187 CNBP GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81188 CSTB GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81189 CSTB GENE FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81190 CSTB GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
FAMIL VRNT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81200 ASPA GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 315 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81201 APC GENE FULL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
SEQUENCE more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81202 APC GENE KNOWN FAM Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81203 APC GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81204 AR GENE CHARAC ALLELES Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81205 BCKDHB GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81206 BCR/ABL1 GENE MAJOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
BP more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81207 BCR/ABL1 GENE MINOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
BP more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81208 BCR/ABL1 GENE OTHER Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
BP more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 316 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81209 BLM GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81210 BRAF GENE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81210 BRAF GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81212 BRCA1&2 Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
185&5385&6174 VAR more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81215 BRCA1 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
FAM VARIANT more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81216 BRCA2 GENE FULL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
SEQUENCE more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81217 BRCA2 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Breast Genetic Testing for
NH-Genetic
FAM VARIANT more details and Ovarian Cancer Syndrome Hereditary Breast and
Testing Ovarian Cancer Syndrome (Eff
03/09/18 and Retired

81217 BRCA2 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
FAM VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 317 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81218 CEBPA GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81219 CALR GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81220 CFTR GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81221 CFTR GENE KNOWN FAM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81222 CFTR GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81223 CFTR GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81224 CFTR GENE INTRON POLY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
T more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81225 CYP2C19 GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 318 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81226 CYP2D6 GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81227 CYP2C9 GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81228 CYTOGEN MICRARRAY Yes Please review the Well Sense Policy for Chromosomal Microarray Analysis Chromosomal Microarray Chromosomal
NH-Genetic
COPY NMBR more details for Unexplained Intellectual Analysis for Unexplained Microarray Analysis for
Testing Disabilities and/or Multiple Intellectual Disabilities and/or Unexplained Intellectual
Congenital Anomalies Multiple ( Eff 02/01/18 and Disabilities and/or

81228 CYTOGEN MICRARRAY Yes Please review the Well Sense Policy for Chromosomal Microarray Analysis Chromosomal Microarray Chromosomal
NH-Genetic
COPY NMBR more details for Unexplained Intellectual Analysis for Unexplained Microarray Analysis for
Testing Disabilities and/or Multiple Intellectual Disabilities and/or Unexplained Intellectual
Congenital Anomalies Multiple ( Eff 02/01/18 and Disabilities and/or

81228 CYTOGEN MICRARRAY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
COPY NMBR more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81229 CYTOGEN M ARRAY COPY Yes Please review the Well Sense Policy for Chromosomal Microarray Analysis Chromosomal Microarray Chromosomal
NH-Genetic
NO&SNP more details for Unexplained Intellectual Analysis for Unexplained Microarray Analysis for
Testing Disabilities and/or Multiple Intellectual Disabilities and/or Unexplained Intellectual
Congenital Anomalies Multiple ( Eff 02/01/18 and Disabilities and/or

81229 CYTOGEN M ARRAY COPY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
NO&SNP more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81229 CYTOGEN M ARRAY COPY Yes Please review the Well Sense Policy for Chromosomal Microarray Analysis Chromosomal Microarray Chromosomal
NH-Genetic
NO&SNP more details for Unexplained Intellectual Analysis for Unexplained Microarray Analysis for
Testing Disabilities and/or Multiple Intellectual Disabilities and/or Unexplained Intellectual
Congenital Anomalies Multiple ( Eff 02/01/18 and Disabilities and/or

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 319 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81230 CYP3A4 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81231 CYP3A5 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81232 DPYD GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81233 BTK GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81234 DMPK GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLELE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81235 EGFR GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81236 EZH2 GENE FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81237 EZH2 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 320 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81238 F9 FULL GENE SEQUENCE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81239 DMPK GENE CHARAC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81240 F2 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81240 F2 GENE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Thrombophilia Hereditary Thrombophilia (Eff Hereditary
Testing 04/01/18 and Retired Thrombophilia (Eff
031/31/19) 04/01/19)

81241 F5 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81241 F5 GENE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Thrombophilia Hereditary Thrombophilia (Eff Hereditary
Testing 04/01/18 and Retired Thrombophilia (Eff
031/31/19) 04/01/19)

81242 FANCC GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81243 FMR1 GENE DETECTION Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 321 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81244 FMR1 GENE Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
CHARACTERIZATION more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81245 FLT3 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81246 FLT3 GENE ANALYSIS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81247 G6PD GENE ALYS CMN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81248 G6PD KNOWN FAMILIAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81249 G6PD FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81250 G6PC GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81251 GBA GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 322 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81252 GJB2 GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81253 GJB2 GENE KNOWN FAM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81254 GJB6 GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81255 HEXA GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81256 HFE GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81257 HBA1/HBA2 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81258 HBA1/HBA2 GENE FAM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VRNT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81259 HBA1/HBA2 FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 323 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81260 IKBKAP GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81261 IGH GENE REARRANGE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
AMP METH more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81262 IGH GENE REARRANG DIR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PROBE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81263 IGH VARI REGIONAL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
MUTATION more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81264 IGK REARRANGEABN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
CLONAL POP more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81265 STR MARKERS SPECIMEN No

ANAL

81266 STR MARKERS SPEC ANAL No

ADDL

81267 CHIMERISM ANAL NO No

CELL SELEC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 324 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81268 CHIMERISM ANAL No

W/CELL SELECT

81269 HBA1/HBA2 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DUP/DEL VRNTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81270 JAK2 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81271 HTT GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81272 KIT GENE TARGETED SEQ No

ANALYS

81273 KIT GENE ANALYS D816 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81274 HTT GENE CHARAC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81275 KRAS GENE VARIANTS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
EXON 2 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 325 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81276 KRAS GENE ADDL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81283 IFNL3 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81284 FXN GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81285 FXN GENE CHARAC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81286 FXN GENE FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81287 MGMT GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
METHYLATION ANAL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81288 MLH1 GENE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81289 FXN GENE KNOWN FAMIL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 326 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81290 MCOLN1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81291 MTHFR GENE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Thrombophilia Hereditary Thrombophilia (Eff Hereditary
Testing 04/01/18 and Retired Thrombophilia (Eff
031/31/19) 04/01/19)

81291 MTHFR GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81292 MLH1 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81293 MLH1 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81294 MLH1 GENE DUP/DELETE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANT more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81295 MSH2 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81296 MSH2 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 327 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81297 MSH2 GENE DUP/DELETE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANT more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81298 MSH6 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81299 MSH6 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81300 MSH6 GENE DUP/DELETE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANT more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81301 MICROSATELLITE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
INSTABILITY more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81302 MECP2 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81303 MECP2 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81304 MECP2 GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 328 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81305 MYD88 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
P.LEU265PRO VRNT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81306 NUDT15 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81310 NPM1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81311 NRAS GENE VARIANTS Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
EXON 2&3 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81312 PABPN1 GENE DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81313 PCA3/KLK3 ANTIGEN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81314 PDGFRA GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81315 PML/RARALPHA COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
BREAKPOINTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 329 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81316 PML/RARALPHA 1 Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
BREAKPOINT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81317 PMS2 GENE FULL SEQ Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
ANALYSIS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81318 PMS2 KNOWN FAMILIAL Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81319 PMS2 GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
VARIANTS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81320 PLCG2 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81321 PTEN GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81322 PTEN GENE KNOWN FAM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81323 PTEN GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 330 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81324 PMP22 GENE DUP/DELET Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81325 PMP22 GENE FULL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81326 PMP22 GENE KNOWN Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
FAM VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81327 SEPT9 METHYLATION Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
ANALYSIS more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81328 SLCO1B1 GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81329 SMN1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
DOS/DELETION ALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81330 SMPD1 GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81331 SNRPN/UBE3A GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 331 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81332 SERPINA1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81333 TGFBI GENE COMMON Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81334 RUNX1 GENE TARGETED Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQ ALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81335 TPMT GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81336 SMN1 GENE FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81337 SMN1 GEN NOWN FAMIL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQ VRNT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81340 TRB@ GENE REARRANGE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
AMPLIFY more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81341 TRB@ GENE REARRANGE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
DIRPROBE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 332 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81342 TRG GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
REARRANGEMENT ANAL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81343 PPP2R2B GEN DETC Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ABNOR ALLEL more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81344 TBP GENE DETC ABNOR Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
ALLELES more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81345 TERT GENE TARGETED Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
SEQ ALYS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81346 TYMS GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81350 UGT1A1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81355 VKORC1 GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81361 HBB GENE COM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 333 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81362 HBB GENE KNOWN FAM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANT more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81363 HBB GENE DUP/DEL Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
VARIANTS more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81364 HBB FULL GENE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
SEQUENCE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81370 HLA I & II TYPING LR No

81371 HLA I & II TYPE VERIFY LR No

81372 HLA I TYPING COMPLETE No

LR

81373 HLA I TYPING 1 LOCUS LR No

81374 HLA I TYPING 1 ANTIGEN No

LR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 334 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81375 HLA II TYPING AG EQUIV No

LR

81376 HLA II TYPING 1 LOCUS LR No

81377 HLA II TYPE 1 AG EQUIV No

LR

81378 HLA I & II TYPING HR No

81379 HLA I TYPING COMPLETE No

HR

81380 HLA I TYPING 1 LOCUS HR No

81381 HLA I TYPING 1 ALLELE HR No

81382 HLA II TYPING 1 LOC HR No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 335 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81383 HLA II TYPING 1 ALLELE No

HR

81400 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 1 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81400 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
LEVEL 1 more details Thrombophilia Hereditary Thrombophilia (Eff Hereditary
Testing 04/01/18 and Retired Thrombophilia (Eff
031/31/19) 04/01/19)

81401 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
LEVEL 2 more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81401 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 2 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81401 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
LEVEL 2 more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81402 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 3 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81403 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 4 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 336 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81404 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 5 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81404 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
LEVEL 5 more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81404 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Familial Genetic Testing for Familial
NH-Genetic
LEVEL 5 more details Malignant Melanoma Malignant Melanoma ( Eff
Testing 01/01/19)

81405 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Fragile X- Genetic Testing for Fragile X- Genetic Testing for
NH-Genetic
LEVEL 6 more details Associated Disorders Associated Disorders ( Eff Fragile X-Associated
Testing 02/01/18 and Retired Disorders ( Eff 04/01/19)
03/31/19)

81405 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 6 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81406 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 7 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81406 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing for Hereditary Genetic Testing for Genetic Testing for
NH-Genetic
LEVEL 7 more details Colorectal Cancer Hereditary Colorectal Cancer Hereditary Colorectal
Testing ( Eff 03/09/18 and Retired Cancer ( Eff 04/01/19)
03/31/19)

81407 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 8 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 337 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81408 MOPATH PROCEDURE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
LEVEL 9 more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

Multianalyte Assays with Algorithmic Analyses

81490 AUTOIMMUNE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
RHEUMATOID ARTHR more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81493 COR ARTERY DISEASE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
MRNA more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81500 ONCO (OVAR) TWO No

PROTEINS

81503 ONCO (OVAR) FIVE No

PROTEINS

81504 ONCOLOGY TISSUE OF No

ORIGIN

81506 ENDO ASSAY SEVEN ANAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 338 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81507 FETAL ANEUPLOIDY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
TRISOM RISK more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81508 FTL CGEN ABNOR TWO No

PROTEINS

81509 FTL CGEN ABNOR 3 No

PROTEINS

81510 FTL CGEN ABNOR THREE No

ANAL

81511 FTL CGEN ABNOR FOUR No

ANAL

81512 FTL CGEN ABNOR FIVE No

ANAL

81519 ONCOLOGY BREAST Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
NH-Genetic
MRNA more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Testing Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

81519 ONCOLOGY BREAST Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
NH-Genetic
MRNA more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Testing Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 339 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81520 ONC BREAST MRNA 58 Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
GENES more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

81521 ONC BREAST MRNA 70 Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
GENES more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

81525 ONCOLOGY COLON MRNA Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

81528 ONCOLOGY COLORECTAL Yes Please review the Well Sense Policy for DNA Testing of Stool Samples with DNA Testing of Stool w
NH-Genetic
SCR more details Cologuard™ to Screen for Colorguard for Colorectal
Testing Colorectal Cancer Cancer Screen (Eff 06/01/18)

81535 ONCOLOGY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
GYNECOLOGIC more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81536 ONCOLOGY Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
GYNECOLOGIC more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81538 ONCOLOGY LUNG Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81539 ONCOLOGY PROSTATE Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
PROB SCORE more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 340 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81540 ONCOLOGY TUM Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
UNKNOWN ORIGIN more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81541 ONC PROSTATE MRNA 46 Yes Please review the Well Sense Policy for Gene Expression Profiling of Tumor Gene Expression Profiling of Gene Expression
NH-Genetic
GENES more details Tissue (Oncotype DX™ and Other Tumor Tissue (Oncotype DX™ Profiling of Tumor Tissue
Testing Tests) and Other Tests) ( Eff (Oncotype DX™ and
10/01/18 and Retired Other Tests) ( Eff

81545 ONCOLOGY THYROID Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81551 ONC PROSTATE 3 GENES Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81595 CARDIOLOGY HRT Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
TRNSPL MRNA more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

81599 UNLISTED MAAA No

organ or disease-oriented panels

80047 METABOLIC PANEL No
IONIZED CA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 341 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80048 METABOLIC PANEL No

TOTAL CA

80050 GENERAL HEALTH PANEL No

80051 ELECTROLYTE PANEL No

80053 COMPREHEN METABOLIC No

PANEL

80055 OBSTETRIC PANEL No

80061 LIPID PANEL No

80069 RENAL FUNCTION PANEL No

80074 ACUTE HEPATITIS PANEL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 342 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80076 HEPATIC FUNCTION No

PANEL

80081 OBSTETRIC PANEL No

other procedures
88749 IN VIVO LAB SERVICE No

89049 CHCT FOR MAL No

HYPERTHERMIA

89050 BODY FLUID CELL COUNT No

89051 BODY FLUID CELL COUNT No

89055 LEUKOCYTE ASSESSMENT No

FECAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 343 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89060 EXAM SYNOVIAL FLUID No

CRYSTALS

89125 SPECIMEN FAT STAIN No

89160 EXAM FECES FOR MEAT No

FIBERS

89190 NASAL SMEAR FOR No

EOSINOPHILS

89220 SPUTUM SPECIMEN No

COLLECTION

89230 COLLECT SWEAT FOR No

TEST

89240 PATHOLOGY LAB No

PROCEDURE

proprietary laboratory analyses

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 344 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0009U ONC BRST CA ERBB2 Yes* Please review BMCHP criteria for details. Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
AMP/NONAMP *Will be covered only when performed in Pharmacogenetics Pharmacogenetics (Eff Testing and
AMP/NONAMP the Outpatient setting. 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0015U RX METAB ADVRS RX RXN Yes* Please review BMCHP criteria for details. Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
DNA *Will be covered only when performed in Pharmacogenetics Pharmacogenetics (Eff Testing and
the Outpatient setting. 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0016U ONC HMTLMF NEO RNA Yes* Please review BMCHP criteria for details. Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
BCR/ABL1 *Will be covered only when performed in Pharmacogenetics Pharmacogenetics (Eff Testing and
the Outpatient setting. 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0017U ONC HMTLMF NEO JAK2 Yes* Please review BMCHP criteria for details. Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
MUT DNA *Will be covered only when performed in Pharmacogenetics Pharmacogenetics (Eff Testing and
the Outpatient setting. 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

reproductive medicine procedures

89250 CULTR OOCYTE/EMBRYO No
<4 DAYS

89251 CULTR OOCYTE/EMBRYO No

<4 DAYS

89253 EMBRYO HATCHING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 345 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89254 OOCYTE IDENTIFICATION No

89255 PREPARE EMBRYO FOR No

TRANSFER

89257 SPERM IDENTIFICATION No

89258 CRYOPRESERVATION No
EMBRYO(S)

89259 CRYOPRESERVATION No
SPERM

89260 SPERM ISOLATION No

SIMPLE

89261 SPERM ISOLATION No

COMPLEX

89264 IDENTIFY SPERM TISSUE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 346 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89268 INSEMINATION OF No
OOCYTES

89272 EXTENDED CULTURE OF No

OOCYTES

89280 ASSIST OOCYTE No

FERTILIZATION

89281 ASSIST OOCYTE No

FERTILIZATION

89290 BIOPSY OOCYTE POLAR No

BODY

89291 BIOPSY OOCYTE POLAR No

BODY

89300 SEMEN ANALYSIS No

W/HUHNER

89310 SEMEN ANALYSIS No

W/COUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 347 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89320 SEMEN ANAL No

VOL/COUNT/MOT

89321 SEMEN ANAL SPERM No

DETECTION

89322 SEMEN ANAL STRICT No

CRITERIA

89325 SPERM ANTIBODY TEST No

89329 SPERM EVALUATION TEST No

89330 EVALUATION CERVICAL No

MUCUS

89331 RETROGRADE No
EJACULATION ANAL

89335 CRYOPRESERVE No
TESTICULAR TISS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 348 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89337 CRYOPRESERVATION No
OOCYTE(S)

89342 STORAGE/YEAR No
EMBRYO(S)

89343 STORAGE/YEAR No
SPERM/SEMEN

89344 STORAGE/YEAR REPROD No

TISSUE

89346 STORAGE/YEAR No
OOCYTE(S)

89352 THAWING No
CRYOPRESRVED EMBRYO

89353 THAWING No
CRYOPRESRVED SPERM

89354 THAW CRYOPRSVRD No

REPROD TISS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 349 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

89356 THAWING No
CRYOPRESRVED OOCYTE

89398 UNLISTED REPROD MED No

LAB PROC

surgical pathology
88300 SURGICAL PATH GROSS No

88302 TISSUE EXAM BY No

PATHOLOGIST

88304 TISSUE EXAM BY No

PATHOLOGIST

88305 TISSUE EXAM BY No

PATHOLOGIST

88307 TISSUE EXAM BY No

PATHOLOGIST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 350 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88309 TISSUE EXAM BY No

PATHOLOGIST

88311 DECALCIFY TISSUE No

88312 SPECIAL STAINS GROUP 1 No

88313 SPECIAL STAINS GROUP 2 No

88314 HISTOCHEMICAL STAINS No

ADD-ON

88319 ENZYME No
HISTOCHEMISTRY

88321 MICROSLIDE No
CONSULTATION

88323 MICROSLIDE No
CONSULTATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 351 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88325 COMPREHENSIVE No
REVIEW OF DATA

88329 PATH CONSULT INTROP No

88331 PATH CONSULT INTRAOP No

1 BLOC

88332 PATH CONSULT INTRAOP No

ADDL

88333 INTRAOP CYTO PATH No

CONSULT 1

88334 INTRAOP CYTO PATH No

CONSULT 2

88341 IMMUNOHISTO No
ANTIBODY SLIDE

88342 IMMUNOHISTO ANTB No

1ST STAIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 352 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88344 IMMUNOHISTO No
ANTIBODY SLIDE

88346 IMMUNOFLUOR ANTB No

1ST STAIN

88348 ELECTRON MICROSCOPY No

88350 IMMUNOFLUOR ANTB No

ADDL STAIN

88355 ANALYSIS SKELETAL No

MUSCLE

88356 ANALYSIS NERVE No

88358 ANALYSIS TUMOR No

88360 TUMOR No
IMMUNOHISTOCHEM/MA
NUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 353 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88361 TUMOR No
IMMUNOHISTOCHEM/CO
MPUT

88362 NERVE TEASING No

PREPARATIONS

88363 XM ARCHIVE TISSUE No

MOLEC ANAL

88364 INSITU HYBRIDIZATION No

(FISH)

88365 INSITU HYBRIDIZATION No

(FISH)

88366 INSITU HYBRIDIZATION No

(FISH)

88367 INSITU HYBRIDIZATION No

AUTO

88368 INSITU HYBRIDIZATION No

MANUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 354 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88369 M/PHMTRC No
ALYSISHQUANT/SEMIQ

88371 PROTEIN WESTERN BLOT No

TISSUE

88372 PROTEIN ANALYSIS No

W/PROBE

88373 M/PHMTRC ALYS No

ISHQUANT/SEMIQ

88374 M/PHMTRC ALYS No

ISHQUANT/SEMIQ

88375 OPTICAL No
ENDOMICROSCPY INTERP

88377 M/PHMTRC ALYS No

ISHQUANT/SEMIQ

88380 MICRODISSECTION LASER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 355 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

88381 MICRODISSECTION No
MANUAL

88387 TISS EXAM MOLECULAR No

STUDY

88388 TISS EX MOLECUL STUDY No

ADD-ON

88399 SURGICAL PATHOLOGY No

PROCEDURE

therapeutic drug assays

80150 ASSAY OF AMIKACIN No

80155 DRUG ASSAY CAFFEINE No

80156 ASSAY CARBAMAZEPINE No

TOTAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 356 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80157 ASSAY CARBAMAZEPINE No

FREE

80158 DRUG ASSAY No

CYCLOSPORINE

80159 DRUG ASSAY CLOZAPINE No

80162 ASSAY OF DIGOXIN TOTAL No

80163 ASSAY OF DIGOXIN FREE No

80164 ASSAY DIPROPYLACETIC No

ACD TOT

80165 DIPROPYLACETIC ACID No

FREE

80168 ASSAY OF ETHOSUXIMIDE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 357 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80169 DRUG ASSAY No

EVEROLIMUS

80170 ASSAY OF GENTAMICIN No

80171 DRUG SCREEN QUANT No

GABAPENTIN

80173 ASSAY OF HALOPERIDOL No

80175 DRUG SCREEN QUAN No

LAMOTRIGINE

80176 ASSAY OF LIDOCAINE No

80177 DRUG SCRN QUAN No

LEVETIRACETAM

80178 ASSAY OF LITHIUM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 358 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80180 DRUG SCRN QUAN No

MYCOPHENOLATE

80183 DRUG SCRN QUANT No

OXCARBAZEPIN

80184 ASSAY OF No
PHENOBARBITAL

80185 ASSAY OF PHENYTOIN No

TOTAL

80186 ASSAY OF PHENYTOIN No

FREE

80188 ASSAY OF PRIMIDONE No

80190 ASSAY OF PROCAINAMIDE No

80192 ASSAY OF PROCAINAMIDE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 359 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80194 ASSAY OF QUINIDINE No

80195 ASSAY OF SIROLIMUS No

80197 ASSAY OF TACROLIMUS No

80198 ASSAY OF THEOPHYLLINE No

80199 DRUG SCREEN QUANT No

TIAGABINE

80200 ASSAY OF TOBRAMYCIN No

80201 ASSAY OF TOPIRAMATE No

80202 ASSAY OF VANCOMYCIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 360 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

80203 DRUG SCREEN QUANT No

ZONISAMIDE

80299 QUANTITATIVE ASSAY No

DRUG

transfusion medicine
86850 RBC ANTIBODY SCREEN No

86860 RBC ANTIBODY ELUTION No

86870 RBC ANTIBODY No

IDENTIFICATION

86880 COOMBS TEST DIRECT No

86885 COOMBS TEST INDIRECT No

QUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 361 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86886 COOMBS TEST INDIRECT No

TITER

86890 AUTOLOGOUS BLOOD No

PROCESS

86891 AUTOLOGOUS BLOOD OP No

SALVAGE

86900 BLOOD TYPING No

SEROLOGIC ABO

86901 BLOOD TYPING No

SEROLOGIC RH(D)

86902 BLOOD TYPE ANTIGEN No

DONOR EA

86904 BLOOD TYPING PATIENT No

SERUM

86905 BLOOD TYPING RBC No

ANTIGENS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 362 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86906 BLD TYPING SEROLOGIC No

RH PHNT

86910 BLOOD TYPING Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
PATERNITY TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

86911 BLOOD TYPING ANTIGEN Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
SYSTEM more details Treatment Investigational Treatmen
Experimental/I
nvestigation

86920 COMPATIBILITY TEST SPIN No

86921 COMPATIBILITY TEST No

INCUBATE

86922 COMPATIBILITY TEST No

ANTIGLOB

86923 COMPATIBILITY TEST No

ELECTRIC

86927 PLASMA FRESH FROZEN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 363 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86930 FROZEN BLOOD PREP No

86931 FROZEN BLOOD THAW No

86932 FROZEN BLOOD No

FREEZE/THAW

86940 HEMOLYSINS/AGGLUTINI No
NS AUTO

86941 HEMOLYSINS/AGGLUTINI No
NS

86945 BLOOD No
PRODUCT/IRRADIATION

86950 LEUKACYTE TRANSFUSION No

86960 VOL REDUCTION OF No

BLOOD/PROD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 364 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86965 POOLING BLOOD No

PLATELETS

86970 RBC PRETX INCUBATJ No

W/CHEMICL

86971 RBC PRETX INCUBATJ No

W/ENZYMES

86972 RBC PRETX INCUBATJ No

W/DENSITY

86975 RBC SERUM PRETX No

INCUBJ DRUGS

86976 RBC SERUM PRETX ID No

DILUTION

86977 RBC SERUM PRETX No

INCUBJ/INHIB

86978 RBC PRETREATMENT No

SERUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 365 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

86985 SPLIT BLOOD OR No

PRODUCTS

86999 TRANSFUSION No
PROCEDURE

urinalysis
81000 URINALYSIS NONAUTO No
W/SCOPE

81001 URINALYSIS AUTO No

W/SCOPE

81002 URINALYSIS NONAUTO No

W/O SCOPE

81003 URINALYSIS AUTO W/O No

SCOPE

81005 URINALYSIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 366 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

81007 URINE SCREEN FOR No

BACTERIA

81015 MICROSCOPIC EXAM OF No

URINE

81020 URINALYSIS GLASS TEST No

81025 URINE PREGNANCY TEST No

81050 URINALYSIS VOLUME No

MEASURE

81099 URINALYSIS TEST No

PROCEDURE

Codes for Radiology

bone/joint studies
77071 X-RAY STRESS VIEW No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 367 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77072 X-RAYS FOR BONE AGE No

77073 X-RAYS BONE LENGTH No

STUDIES

77074 X-RAYS BONE SURVEY No

LIMITED

77075 X-RAYS BONE SURVEY No

COMPLETE

77076 X-RAYS BONE SURVEY No

INFANT

77077 JOINT SURVEY SINGLE No

VIEW

77078 CT BONE DENSITY AXIAL Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

77080 DXA BONE DENSITY AXIAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 368 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77081 DXA BONE No

DENSITY/PERIPHERAL

77084 MAGNETIC IMAGE BONE Yes For information about PA requirements, eviCore
eviCore
MARROW please contact eviCore, Inc. via FAX 888-
693-3210

77085 DXA BONE DENSITY No

STUDY

77086 FRACTURE ASSESSMENT No

VIA DXA

breast mammography
77051 COMPUTER DX No
MAMMOGRAM ADD-ON

77052 COMP SCREEN No

MAMMOGRAM ADD-ON

77053 X-RAY OF MAMMARY No

DUCT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 369 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77054 X-RAY OF MAMMARY No

DUCTS

77055 MAMMOGRAM ONE No

BREAST

77056 MAMMOGRAM BOTH No

BREASTS

77057 MAMMOGRAM No
SCREENING

77058 MRI ONE BREAST Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

77059 MRI BOTH BREASTS Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

77061 BREAST TOMOSYNTHESIS No

UNI

77062 BREAST TOMOSYNTHESIS No

BI

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 370 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77063 BREAST TOMOSYNTHESIS No

BI

diagnostic imaging
70010 CONTRAST X-RAY OF No
BRAIN

70015 CONTRAST X-RAY OF No

BRAIN

70030 X-RAY EYE FOR FOREIGN No

BODY

70100 X-RAY EXAM OF JAW No

<4VIEWS

70110 X-RAY EXAM OF JAW 4/> No

VIEWS

70120 X-RAY EXAM OF No

MASTOIDS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 371 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70130 X-RAY EXAM OF No

MASTOIDS

70134 X-RAY EXAM OF MIDDLE No

EAR

70140 X-RAY EXAM OF FACIAL No

BONES

70150 X-RAY EXAM OF FACIAL No

BONES

70160 X-RAY EXAM OF NASAL No

BONES

70170 X-RAY EXAM OF TEAR No

DUCT

70190 X-RAY EXAM OF EYE No

SOCKETS

70200 X-RAY EXAM OF EYE No

SOCKETS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 372 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70210 X-RAY EXAM OF SINUSES No

70220 X-RAY EXAM OF SINUSES No

70240 X-RAY EXAM PITUITARY No

SADDLE

70250 X-RAY EXAM OF SKULL No

70260 X-RAY EXAM OF SKULL No

70300 X-RAY EXAM OF TEETH No

70310 X-RAY EXAM OF TEETH No

70320 FULL MOUTH X-RAY OF No

TEETH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 373 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70328 X-RAY EXAM OF JAW No

JOINT

70330 X-RAY EXAM OF JAW No

JOINTS

70332 X-RAY EXAM OF JAW No

JOINT

70336 MAGNETIC IMAGE JAW Yes For information about PA requirements, eviCore
eviCore
JOINT please contact eviCore, Inc. via FAX 888-
693-3210

70350 X-RAY HEAD FOR No

ORTHODONTIA

70355 PANORAMIC X-RAY OF No

JAWS

70360 X-RAY EXAM OF NECK No

70370 THROAT X-RAY & No

FLUOROSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 374 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70371 SPEECH EVALUATION No

COMPLEX

70380 X-RAY EXAM OF No

SALIVARY GLAND

70390 X-RAY EXAM OF No

SALIVARY DUCT

70450 CT HEAD/BRAIN W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

70460 CT HEAD/BRAIN W/DYE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

70470 CT HEAD/BRAIN W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70480 CT ORBIT/EAR/FOSSA Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

70481 CT ORBIT/EAR/FOSSA Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 375 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70482 CT ORBIT/EAR/FOSSA Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70486 CT MAXILLOFACIAL W/O Yes For information about PA requirements, eviCore

eviCore
DYE please contact eviCore, Inc. via FAX 888-
693-3210

70487 CT MAXILLOFACIAL Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70488 CT MAXILLOFACIAL W/O Yes For information about PA requirements, eviCore

eviCore
& W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70490 CT SOFT TISSUE NECK Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

70491 CT SOFT TISSUE NECK Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70492 CT SFT TSUE NCK W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70496 CT ANGIOGRAPHY HEAD Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 376 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70498 CT ANGIOGRAPHY NECK Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

70540 MRI ORBIT/FACE/NECK Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

70542 MRI ORBIT/FACE/NECK Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70543 MRI ORBT/FAC/NCK W/O Yes For information about PA requirements, eviCore
eviCore
&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70544 MR ANGIOGRAPHY HEAD Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

70545 MR ANGIOGRAPHY HEAD Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70546 MR ANGIOGRAPH HEAD Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70547 MR ANGIOGRAPHY NECK Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 377 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70548 MR ANGIOGRAPHY NECK Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70549 MR ANGIOGRAPH NECK Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70551 MRI BRAIN STEM W/O Yes For information about PA requirements, eviCore
eviCore
DYE please contact eviCore, Inc. via FAX 888-
693-3210

70552 MRI BRAIN STEM W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

70553 MRI BRAIN STEM W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

70554 FMRI BRAIN BY TECH Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

70555 FMRI BRAIN BY Yes For information about PA requirements, eviCore

eviCore
PHYS/PSYCH please contact eviCore, Inc. via FAX 888-
693-3210

70557 MRI BRAIN W/O DYE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 378 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

70558 MRI BRAIN W/DYE No

70559 MRI BRAIN W/O & W/DYE No

71010 CHEST X-RAY 1 VIEW No

FRONTAL

71015 CHEST X-RAY STEREO No

FRONTAL

71020 CHEST X-RAY 2VW No

FRONTAL&LATL

71021 CHEST X-RAY FRNT LAT No

LORDOTC

71022 CHEST X-RAY FRNT LAT No

OBLIQUE

71023 CHEST X-RAY AND No

FLUOROSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 379 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

71030 CHEST X-RAY 4/> VIEWS No

71034 CHEST X-RAY&FLUORO No

4/> VIEWS

71035 CHEST X-RAY SPECIAL No

VIEWS

71100 X-RAY EXAM RIBS UNI 2 No

VIEWS

71101 X-RAY EXAM UNILAT No

RIBS/CHEST

71110 X-RAY EXAM RIBS BIL 3 No

VIEWS

71111 X-RAY EXAM No

RIBS/CHEST4/> VWS

71120 X-RAY EXAM No

BREASTBONE 2/>VWS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 380 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

71130 X-RAY STRENOCLAVIC JT No

3/>VWS

71250 CT THORAX W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

71260 CT THORAX W/DYE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

71270 CT THORAX W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

71275 CT ANGIOGRAPHY CHEST Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

71550 MRI CHEST W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

71551 MRI CHEST W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

71552 MRI CHEST W/O & W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 381 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

71555 MRI ANGIO CHEST W OR Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

72020 X-RAY EXAM OF SPINE 1 No

VIEW

72040 X-RAY EXAM NECK SPINE No

2-3 VW

72050 X-RAY EXAM NECK SPINE No

4/5VWS

72052 X-RAY EXAM NECK SPINE No

6/>VWS

72070 X-RAY EXAM THORAC No

SPINE 2VWS

72072 X-RAY EXAM THORAC No

SPINE 3VWS

72074 X-RAY EXAM THORAC No

SPINE4/>VW

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 382 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72080 X-RAY EXAM No

THORACOLMB 2/> VW

72081 X-RAY EXAM ENTIRE SPI 1 No

VW

72082 X-RAY EXAM ENTIRE SPI No

2/3 VW

72083 X-RAY EXAM ENTIRE SPI No

4/5 VW

72084 X-RAY EXAM ENTIRE SPI No

6/> VW

72100 X-RAY EXAM L-S SPINE No

2/3 VWS

72110 X-RAY EXAM L-2 SPINE No

4/>VWS

72114 X-RAY EXAM L-S SPINE No

BENDING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 383 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72120 X-RAY BEND ONLY L-S No

SPINE

72125 CT NECK SPINE W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72126 CT NECK SPINE W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72127 CT NECK SPINE W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72128 CT CHEST SPINE W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72129 CT CHEST SPINE W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72130 CT CHEST SPINE W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72131 CT LUMBAR SPINE W/O Yes For information about PA requirements, eviCore
eviCore
DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 384 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72132 CT LUMBAR SPINE W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72133 CT LUMBAR SPINE W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72141 MRI NECK SPINE W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72142 MRI NECK SPINE W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72146 MRI CHEST SPINE W/O Yes For information about PA requirements, eviCore
eviCore
DYE please contact eviCore, Inc. via FAX 888-
693-3210

72147 MRI CHEST SPINE W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72148 MRI LUMBAR SPINE W/O Yes For information about PA requirements, eviCore
eviCore
DYE please contact eviCore, Inc. via FAX 888-
693-3210

72149 MRI LUMBAR SPINE Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 385 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72156 MRI NECK SPINE W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72157 MRI CHEST SPINE W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72158 MRI LUMBAR SPINE W/O Yes For information about PA requirements, eviCore
eviCore
& W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72159 MR ANGIO SPINE Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72170 X-RAY EXAM OF PELVIS No

72190 X-RAY EXAM OF PELVIS No

72191 CT ANGIOGRAPH PELV Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72192 CT PELVIS W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 386 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72193 CT PELVIS W/DYE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72194 CT PELVIS W/O & W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72195 MRI PELVIS W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72196 MRI PELVIS W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

72197 MRI PELVIS W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72198 MR ANGIO PELVIS W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

72200 X-RAY EXAM SI JOINTS No

72202 X-RAY EXAM SI JOINTS No

3/> VWS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 387 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

72220 X-RAY EXAM SACRUM No

TAILBONE

72240 MYELOGRAPHY NECK No

SPINE

72255 MYELOGRAPHY No
THORACIC SPINE

72265 MYELOGRAPHY L-S SPINE No

72270 MYELOGPHY 2/> SPINE No

REGIONS

72275 EPIDUROGRAPHY No

72285 DISCOGRAPHY No
CERV/THOR SPINE

72295 X-RAY OF LOWER SPINE No

DISK

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 388 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73000 X-RAY EXAM OF COLLAR No

BONE

73010 X-RAY EXAM OF No

SHOULDER BLADE

73020 X-RAY EXAM OF No

SHOULDER

73030 X-RAY EXAM OF No

SHOULDER

73040 CONTRAST X-RAY OF No

SHOULDER

73050 X-RAY EXAM OF No

SHOULDERS

73060 X-RAY EXAM OF No

HUMERUS

73070 X-RAY EXAM OF ELBOW No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 389 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73080 X-RAY EXAM OF ELBOW No

73085 CONTRAST X-RAY OF No

ELBOW

73090 X-RAY EXAM OF No

FOREARM

73092 X-RAY EXAM OF ARM No

INFANT

73100 X-RAY EXAM OF WRIST No

73110 X-RAY EXAM OF WRIST No

73115 CONTRAST X-RAY OF No

WRIST

73120 X-RAY EXAM OF HAND No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 390 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73130 X-RAY EXAM OF HAND No

73140 X-RAY EXAM OF No

FINGER(S)

73200 CT UPPER EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73201 CT UPPER EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73202 CT UPPR EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73206 CT ANGIO UPR EXTRM Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73218 MRI UPPER EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73219 MRI UPPER EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 391 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73220 MRI UPPR EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73221 MRI JOINT UPR EXTREM Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73222 MRI JOINT UPR EXTREM Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73223 MRI JOINT UPR EXTR Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73225 MR ANGIO UPR EXTR Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73501 X-RAY EXAM HIP UNI 1 No

VIEW

73502 X-RAY EXAM HIP UNI 2-3 No

VIEWS

73503 X-RAY EXAM HIP UNI 4/> No

VIEWS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 392 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73521 X-RAY EXAM HIPS BI 2 No

VIEWS

73522 X-RAY EXAM HIPS BI 3-4 No

VIEWS

73523 X-RAY EXAM HIPS BI 5/> No

VIEWS

73525 CONTRAST X-RAY OF HIP No

73551 X-RAY EXAM OF FEMUR 1 No

73552 X-RAY EXAM OF FEMUR No

2/>

73560 X-RAY EXAM OF KNEE 1 No

OR 2

73562 X-RAY EXAM OF KNEE 3 No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 393 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73564 X-RAY EXAM KNEE 4 OR No

MORE

73565 X-RAY EXAM OF KNEES No

73580 CONTRAST X-RAY OF No

KNEE JOINT

73590 X-RAY EXAM OF LOWER No

LEG

73592 X-RAY EXAM OF LEG No

INFANT

73600 X-RAY EXAM OF ANKLE No

73610 X-RAY EXAM OF ANKLE No

73615 CONTRAST X-RAY OF No

ANKLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 394 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73620 X-RAY EXAM OF FOOT No

73630 X-RAY EXAM OF FOOT No

73650 X-RAY EXAM OF HEEL No

73660 X-RAY EXAM OF TOE(S) No

73700 CT LOWER EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73701 CT LOWER EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73702 CT LWR EXTREMITY Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73706 CT ANGIO LWR EXTR Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 395 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

73718 MRI LOWER EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73719 MRI LOWER EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73720 MRI LWR EXTREMITY Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73721 MRI JNT OF LWR EXTRE Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

73722 MRI JOINT OF LWR EXTR Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73723 MRI JOINT LWR EXTR Yes For information about PA requirements, eviCore
eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

73725 MR ANG LWR EXT W OR Yes For information about PA requirements, eviCore
eviCore
W/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

74000 X-RAY EXAM OF No

ABDOMEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 396 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74010 X-RAY EXAM OF No

ABDOMEN

74020 X-RAY EXAM OF No

ABDOMEN

74022 X-RAY EXAM SERIES No

ABDOMEN

74150 CT ABDOMEN W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74160 CT ABDOMEN W/DYE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74170 CT ABDOMEN W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

74174 CT ANGIO ABD&PELV Yes For information about PA requirements, eviCore

eviCore
W/O&W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

74175 CT ANGIO ABDOM W/O Yes For information about PA requirements, eviCore
eviCore
& W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 397 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74176 CT ABD & PELVIS W/O Yes For information about PA requirements, eviCore
eviCore
CONTRAST please contact eviCore, Inc. via FAX 888-
693-3210

74177 CT ABD & PELV Yes For information about PA requirements, eviCore
eviCore
W/CONTRAST please contact eviCore, Inc. via FAX 888-
693-3210

74178 CT ABD & PELV 1/> REGNS Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74181 MRI ABDOMEN W/O DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74182 MRI ABDOMEN W/DYE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74183 MRI ABDOMEN W/O & Yes For information about PA requirements, eviCore
eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

74185 MRI ANGIO ABDOM W Yes For information about PA requirements, eviCore
eviCore
ORW/O DYE please contact eviCore, Inc. via FAX 888-
693-3210

74190 X-RAY EXAM OF No

PERITONEUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 398 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74210 CONTRST X-RAY EXAM OF No

THROAT

74220 CONTRAST X-RAY No

ESOPHAGUS

74230 CINE/VID X-RAY No

THROAT/ESOPH

74235 REMOVE ESOPHAGUS No

OBSTRUCTION

74240 X-RAY UPPER GI DELAY No

W/O KUB

74241 X-RAY UPPER GI DELAY No

W/KUB

74245 X-RAY UPPER GI&SMALL No

INTEST

74246 CONTRST X-RAY UPPR GI No

TRACT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 399 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74247 CONTRST X-RAY UPPR GI No

TRACT

74249 CONTRST X-RAY UPPR GI No

TRACT

74250 X-RAY EXAM OF SMALL No

BOWEL

74251 X-RAY EXAM OF SMALL No

BOWEL

74260 X-RAY EXAM OF SMALL No

BOWEL

74261 CT COLONOGRAPHY DX Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

74262 CT COLONOGRAPHY DX Yes For information about PA requirements, eviCore

eviCore
W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

74263 CT COLONOGRAPHY Yes For information about PA requirements, eviCore

eviCore
SCREENING please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 400 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74270 CONTRAST X-RAY EXAM No

OF COLON

74280 CONTRAST X-RAY EXAM No

OF COLON

74283 CONTRAST X-RAY EXAM No

OF COLON

74290 CONTRAST X-RAY No

GALLBLADDER

74300 X-RAY BILE No

DUCTS/PANCREAS

74301 X-RAYS AT SURGERY ADD- No

ON

74328 X-RAY BILE DUCT No

ENDOSCOPY

74329 X-RAY FOR PANCREAS No

ENDOSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 401 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74330 X-RAY BILE/PANC No

ENDOSCOPY

74340 X-RAY GUIDE FOR GI TUBE No

74355 X-RAY GUIDE INTESTINAL No

TUBE

74360 X-RAY GUIDE GI DILATION No

74363 X-RAY BILE DUCT No

DILATION

74400 CONTRST X-RAY URINARY No

TRACT

74410 CONTRST X-RAY URINARY No

TRACT

74415 CONTRST X-RAY URINARY No

TRACT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 402 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74420 CONTRST X-RAY URINARY No

TRACT

74425 CONTRST X-RAY URINARY No

TRACT

74430 CONTRAST X-RAY No

BLADDER

74440 X-RAY MALE GENITAL No

TRACT

74445 X-RAY EXAM OF PENIS No

74450 X-RAY No
URETHRA/BLADDER

74455 X-RAY No
URETHRA/BLADDER

74470 X-RAY EXAM OF KIDNEY No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 403 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

74485 X-RAY GUIDE GU No

DILATION

74710 X-RAY MEASUREMENT No

OF PELVIS

74712 MRI FETAL SNGL/1ST Yes For information about PA requirements, eviCore
GESTATION please contact eviCore, Inc. via FAX 888-
693-3210

74713 MRI FETAL EA ADDL Yes For information about PA requirements, eviCore
GESTATION please contact eviCore, Inc. via FAX 888-
693-3210

74740 X-RAY FEMALE GENITAL No

TRACT

74742 X-RAY FALLOPIAN TUBE No

74775 X-RAY EXAM OF No

PERINEUM

75557 CARDIAC MRI FOR Yes For information about PA requirements, eviCore
eviCore
MORPH please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 404 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75559 CARDIAC MRI W/STRESS Yes For information about PA requirements, eviCore
eviCore
IMG please contact eviCore, Inc. via FAX 888-
693-3210

75561 CARDIAC MRI FOR Yes For information about PA requirements, eviCore
eviCore
MORPH W/DYE please contact eviCore, Inc. via FAX 888-
693-3210

75563 CARD MRI W/STRESS IMG Yes For information about PA requirements, eviCore
eviCore
& DYE please contact eviCore, Inc. via FAX 888-
693-3210

75565 CARD MRI VELOC FLOW Yes For information about PA requirements, eviCore
eviCore
MAPPING please contact eviCore, Inc. via FAX 888-
693-3210

75571 CT HRT W/O DYE W/CA Yes For information about PA requirements, eviCore
eviCore
TEST please contact eviCore, Inc. via FAX 888-
693-3210

75572 CT HRT W/3D IMAGE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

75573 CT HRT W/3D IMAGE Yes For information about PA requirements, eviCore
eviCore
CONGEN please contact eviCore, Inc. via FAX 888-
693-3210

75574 CT ANGIO HRT W/3D Yes For information about PA requirements, eviCore
eviCore
IMAGE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 405 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75600 CONTRAST EXAM No

THORACIC AORTA

75605 CONTRAST EXAM No

THORACIC AORTA

75625 CONTRAST EXAM No

ABDOMINL AORTA

75630 X-RAY AORTA LEG No

ARTERIES

75635 CT ANGIO ABDOMINAL Yes For information about PA requirements, eviCore

eviCore
ARTERIES please contact eviCore, Inc. via FAX 888-
693-3210

75658 ARTERY X-RAYS ARM No

75705 ARTERY X-RAYS SPINE No

75710 ARTERY X-RAYS ARM/LEG No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 406 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75716 ARTERY X-RAYS No

ARMS/LEGS

75726 ARTERY X-RAYS No

ABDOMEN

75731 ARTERY X-RAYS ADRENAL No

GLAND

75733 ARTERY X-RAYS No

ADRENALS

75736 ARTERY X-RAYS PELVIS No

75741 ARTERY X-RAYS LUNG No

75743 ARTERY X-RAYS LUNGS No

75746 ARTERY X-RAYS LUNG No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 407 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75756 ARTERY X-RAYS CHEST No

75774 ARTERY X-RAY EACH No

VESSEL

75791 AV DIALYSIS SHUNT No

IMAGING

75801 LYMPH VESSEL X-RAY No

ARM/LEG

75803 LYMPH VESSEL X-RAY No

ARMS/LEGS

75805 LYMPH VESSEL X-RAY No

TRUNK

75807 LYMPH VESSEL X-RAY No

TRUNK

75809 NONVASCULAR SHUNT X- No

RAY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 408 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75810 VEIN X-RAY SPLEEN/LIVER No

75820 VEIN X-RAY ARM/LEG No

75822 VEIN X-RAY ARMS/LEGS No

75825 VEIN X-RAY TRUNK No

75827 VEIN X-RAY CHEST No

75831 VEIN X-RAY KIDNEY No

75833 VEIN X-RAY KIDNEYS No

75840 VEIN X-RAY ADRENAL No

GLAND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 409 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75842 VEIN X-RAY ADRENAL No

GLANDS

75860 VEIN X-RAY NECK No

75870 VEIN X-RAY SKULL No

75872 VEIN X-RAY SKULL No

EPIDURAL

75880 VEIN X-RAY EYE SOCKET No

75885 VEIN X-RAY LIVER No

W/HEMODYNAM

75887 VEIN X-RAY LIVER W/O No

HEMODYN

75889 VEIN X-RAY LIVER No

W/HEMODYNAM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 410 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75891 VEIN X-RAY LIVER No

75893 VENOUS SAMPLING BY No

CATHETER

75894 X-RAYS TRANSCATH No

THERAPY

75898 FOLLOW-UP No
ANGIOGRAPHY

75901 REMOVE CVA DEVICE No

OBSTRUCT

75902 REMOVE CVA LUMEN No

OBSTRUCT

75952 ENDOVASC REPAIR No

ABDOM AORTA

75953 ABDOM ANEURYSM No

ENDOVAS RPR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 411 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75954 ILIAC ANEURYSM No

ENDOVAS RPR

75956 XRAY ENDOVASC THOR No

AO REPR

75957 XRAY ENDOVASC THOR No

AO REPR

75958 XRAY PLACE PROX EXT No

THOR AO

75959 XRAY PLACE DIST EXT No

THOR AO

75962 REPAIR ARTERIAL No

BLOCKAGE

75964 REPAIR ARTERY No

BLOCKAGE EACH

75966 REPAIR ARTERIAL No

BLOCKAGE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 412 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

75968 REPAIR ARTERY No

BLOCKAGE EACH

75970 VASCULAR BIOPSY No

75978 REPAIR VENOUS No

BLOCKAGE

75984 XRAY CONTROL No

CATHETER CHANGE

75989 ABSCESS DRAINAGE No

UNDER X-RAY

76000 FLUOROSCOPE No
EXAMINATION

76001 FLUOROSCOPE EXAM No

EXTENSIVE

76010 X-RAY NOSE TO RECTUM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 413 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76080 X-RAY EXAM OF FISTULA No

76098 X-RAY EXAM BREAST No

SPECIMEN

76100 X-RAY EXAM OF BODY No

SECTION

76101 COMPLEX BODY SECTION No

X-RAY

76102 COMPLEX BODY SECTION No

X-RAYS

76120 CINE/VIDEO X-RAYS No

76125 CINE/VIDEO X-RAYS ADD- No

ON

76140 X-RAY CONSULTATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 414 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76376 3D RENDER W/INTRP No

POSTPROCES

76377 3D RENDER W/INTRP No

POSTPROCES

76380 CAT SCAN FOLLOW-UP Yes For information about PA requirements, eviCore
eviCore
STUDY please contact eviCore, Inc. via FAX 888-
693-3210

76390 MR SPECTROSCOPY Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

76496 FLUOROSCOPIC No
PROCEDURE

76497 CT PROCEDURE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

76498 MRI PROCEDURE Yes For information about PA requirements, eviCore

eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

76499 RADIOGRAPHIC No
PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 415 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

diagnostic ultrasound
76506 ECHO EXAM OF HEAD No

76510 OPHTH US B & QUANT A No

76511 OPHTH US QUANT A ONLY No

76512 OPHTH US B W/NON- No

QUANT A

76513 ECHO EXAM OF EYE No

WATER BATH

76514 ECHO EXAM OF EYE No

THICKNESS

76516 ECHO EXAM OF EYE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 416 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76519 ECHO EXAM OF EYE No

76529 ECHO EXAM OF EYE No

76536 US EXAM OF HEAD AND No

NECK

76604 US EXAM CHEST No

76641 ULTRASOUND BREAST No

COMPLETE

76642 ULTRASOUND BREAST No

LIMITED

76700 US EXAM ABDOM No

COMPLETE

76705 ECHO EXAM OF No

ABDOMEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 417 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76770 US EXAM ABDO BACK No

WALL COMP

76775 US EXAM ABDO BACK No

WALL LIM

76776 US EXAM K TRANSPL No

W/DOPPLER

76800 US EXAM SPINAL CANAL No

76801 OB US < 14 WKS SINGLE No

FETUS

76802 OB US < 14 WKS ADDL No

FETUS

76805 OB US >/= 14 WKS SNGL No

FETUS

76810 OB US >/= 14 WKS ADDL No

FETUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 418 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76811 OB US DETAILED SNGL No

FETUS

76812 OB US DETAILED ADDL No

FETUS

76813 OB US NUCHAL MEAS 1 No

GEST

76814 OB US NUCHAL MEAS No

ADD-ON

76815 OB US LIMITED FETUS(S) No

76816 OB US FOLLOW-UP PER No

FETUS

76817 TRANSVAGINAL US No
OBSTETRIC

76818 FETAL BIOPHYS PROFILE No

W/NST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 419 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76819 FETAL BIOPHYS PROFIL No

W/O NST

76820 UMBILICAL ARTERY ECHO No

76821 MIDDLE CEREBRAL No

ARTERY ECHO

76825 ECHO EXAM OF FETAL No

HEART

76826 ECHO EXAM OF FETAL No

HEART

76827 ECHO EXAM OF FETAL No

HEART

76828 ECHO EXAM OF FETAL No

HEART

76830 TRANSVAGINAL US NON- No

OB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 420 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76831 ECHO EXAM UTERUS No

76856 US EXAM PELVIC No

COMPLETE

76857 US EXAM PELVIC LIMITED No

76870 US EXAM SCROTUM No

76872 US TRANSRECTAL No

76873 ECHOGRAP TRANS R No

PROS STUDY

76881 US XTR NON-VASC No

COMPLETE

76882 US XTR NON-VASC LMTD No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 421 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76885 US EXAM INFANT HIPS No

DYNAMIC

76886 US EXAM INFANT HIPS No

STATIC

76930 ECHO GUIDE No

CARDIOCENTESIS

76932 ECHO GUIDE FOR HEART No

BIOPSY

76936 ECHO GUIDE FOR ARTERY No

REPAIR

76937 US GUIDE VASCULAR No

ACCESS

76940 US GUIDE TISSUE No

ABLATION

76941 ECHO GUIDE FOR No

TRANSFUSION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 422 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76942 ECHO GUIDE FOR BIOPSY No

76945 ECHO GUIDE VILLUS No

SAMPLING

76946 ECHO GUIDE FOR No

AMNIOCENTESIS

76948 ECHO GUIDE OVA No

ASPIRATION

76965 ECHO GUIDANCE No

RADIOTHERAPY

76970 ULTRASOUND EXAM No

FOLLOW-UP

76975 GI ENDOSCOPIC No
ULTRASOUND

76977 US BONE DENSITY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
MEASURE more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 423 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

76998 US GUIDE INTRAOP No

76999 ECHO EXAMINATION No

PROCEDURE

nuclear medicine
78012 THYROID UPTAKE No
MEASUREMENT

78013 THYROID IMAGING No

W/BLOOD FLOW

78014 THYROID IMAGING No

W/BLOOD FLOW

78015 THYROID MET IMAGING No

78016 THYROID MET No

IMAGING/STUDIES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 424 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78018 THYROID MET IMAGING No

BODY

78020 THYROID MET UPTAKE No

78070 PARATHYROID PLANAR No

IMAGING

78071 PARATHYRD PLANAR No

W/WO SUBTRJ

78072 PARATHYRD PLANAR No

W/SPECT&CT

78075 ADRENAL CORTEX & No

MEDULLA IMG

78099 ENDOCRINE NUCLEAR No

PROCEDURE

78102 BONE MARROW No

IMAGING LTD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 425 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78103 BONE MARROW No

IMAGING MULT

78104 BONE MARROW No

IMAGING BODY

78110 PLASMA VOLUME SINGLE No

78111 PLASMA VOLUME No

MULTIPLE

78120 RED CELL MASS SINGLE No

78121 RED CELL MASS MULTIPLE No

78122 BLOOD VOLUME No

78130 RED CELL SURVIVAL No

STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 426 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78135 RED CELL SURVIVAL No

KINETICS

78140 RED CELL No

SEQUESTRATION

78185 SPLEEN IMAGING No

78190 PLATELET SURVIVAL No

KINETICS

78191 PLATELET SURVIVAL No

78195 LYMPH SYSTEM IMAGING No

78199 BLOOD/LYMPH NUCLEAR No

EXAM

78201 LIVER IMAGING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 427 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78202 LIVER IMAGING WITH No

FLOW

78205 LIVER IMAGING (3D) No

78206 LIVER IMAGE (3D) WITH No

FLOW

78215 LIVER AND SPLEEN No

IMAGING

78216 LIVER & SPLEEN No

IMAGE/FLOW

78226 HEPATOBILIARY SYSTEM No

IMAGING

78227 HEPATOBIL SYST IMAGE No

W/DRUG

78230 SALIVARY GLAND No

IMAGING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 428 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78231 SERIAL SALIVARY No

IMAGING

78232 SALIVARY GLAND No

FUNCTION EXAM

78258 ESOPHAGEAL MOTILITY No

STUDY

78261 GASTRIC MUCOSA No

IMAGING

78262 GASTROESOPHAGEAL No
REFLUX EXAM

78264 GASTRIC EMPTYING No

IMAG STUDY

78265 GASTRIC EMPTYING No

IMAG STUDY

78266 GASTRIC EMPTYING No

IMAG STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 429 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78267 BREATH TST No

ATTAIN/ANAL C-14

78268 BREATH TEST ANALYSIS C- No

14

78270 VIT B-12 ABSORPTION No

EXAM

78271 VIT B-12 ABSRP EXAM No

INT FAC

78272 VIT B-12 ABSORP No

COMBINED

78278 ACUTE GI BLOOD LOSS No

IMAGING

78282 GI PROTEIN LOSS EXAM No

78290 MECKELS DIVERT EXAM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 430 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78291 LEVEEN/SHUNT PATENCY No

EXAM

78299 GI NUCLEAR PROCEDURE No

78300 BONE IMAGING LIMITED No

AREA

78305 BONE IMAGING No

MULTIPLE AREAS

78306 BONE IMAGING WHOLE No

BODY

78315 BONE IMAGING 3 PHASE No

78320 BONE IMAGING (3D) No

78350 BONE MINERAL SINGLE No

PHOTON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 431 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78351 BONE MINERAL DUAL No

PHOTON

78399 MUSCULOSKELETAL No
NUCLEAR EXAM

78414 NON-IMAGING HEART No

FUNCTION

78428 CARDIAC SHUNT No

IMAGING

78445 VASCULAR FLOW No

IMAGING

78451 HT MUSCLE IMAGE SPECT Yes For information about PA requirements, eviCore
eviCore
SING please contact eviCore, Inc. via FAX 888-
693-3210

78452 HT MUSCLE IMAGE SPECT Yes For information about PA requirements, eviCore
eviCore
MULT please contact eviCore, Inc. via FAX 888-
693-3210

78453 HT MUSCLE IMAGE Yes For information about PA requirements, eviCore

eviCore
PLANAR SING please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 432 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78454 HT MUSC IMAGE PLANAR Yes For information about PA requirements, eviCore
eviCore
MULT please contact eviCore, Inc. via FAX 888-
693-3210

78456 ACUTE VENOUS No

THROMBUS IMAGE

78457 VENOUS THROMBOSIS No

IMAGING

78458 VEN THROMBOSIS No

IMAGES BILAT

78459 HEART MUSCLE IMAGING Yes For information about PA requirements, eviCore
eviCore
(PET) please contact eviCore, Inc. via FAX 888-
693-3210

78466 HEART INFARCT IMAGE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78468 HEART INFARCT IMAGE Yes For information about PA requirements, eviCore
eviCore
(EF) please contact eviCore, Inc. via FAX 888-
693-3210

78469 HEART INFARCT IMAGE Yes For information about PA requirements, eviCore
eviCore
(3D) please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 433 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78472 GATED HEART PLANAR Yes For information about PA requirements, eviCore
eviCore
SINGLE please contact eviCore, Inc. via FAX 888-
693-3210

78473 GATED HEART MULTIPLE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78481 HEART FIRST PASS SINGLE Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78483 HEART FIRST PASS Yes For information about PA requirements, eviCore
eviCore
MULTIPLE please contact eviCore, Inc. via FAX 888-
693-3210

78491 HEART IMAGE (PET) Yes For information about PA requirements, eviCore
eviCore
SINGLE please contact eviCore, Inc. via FAX 888-
693-3210

78492 HEART IMAGE (PET) Yes For information about PA requirements, eviCore
eviCore
MULTIPLE please contact eviCore, Inc. via FAX 888-
693-3210

78494 HEART IMAGE SPECT Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78496 HEART FIRST PASS ADD- Yes For information about PA requirements, eviCore
eviCore
ON please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 434 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78499 CARDIOVASCULAR Yes For information about PA requirements, eviCore

eviCore
NUCLEAR EXAM please contact eviCore, Inc. via FAX 888-
693-3210

78579 LUNG VENTILATION No

IMAGING

78580 LUNG PERFUSION No

IMAGING

78582 LUNG VENTILAT&PERFUS No

IMAGING

78597 LUNG PERFUSION No

DIFFERENTIAL

78598 LUNG PERF&VENTILAT No

DIFERENTL

78599 RESPIRATORY NUCLEAR No

EXAM

78600 BRAIN IMAGE < 4 VIEWS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 435 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78601 BRAIN IMAGE W/FLOW < No

4 VIEWS

78605 BRAIN IMAGE 4+ VIEWS No

78606 BRAIN IMAGE W/FLOW 4 No

+ VIEWS

78607 BRAIN IMAGING (3D) No

78608 BRAIN IMAGING (PET) Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78609 BRAIN IMAGING (PET) Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78610 BRAIN FLOW IMAGING No

ONLY

78630 CEREBROSPINAL FLUID No

SCAN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 436 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78635 CSF VENTRICULOGRAPHY No

78645 CSF SHUNT EVALUATION No

78647 CEREBROSPINAL FLUID No

SCAN

78650 CSF LEAKAGE IMAGING No

78660 NUCLEAR EXAM OF TEAR No

FLOW

78699 NERVOUS SYSTEM No

NUCLEAR EXAM

78700 KIDNEY IMAGING No

MORPHOL

78701 KIDNEY IMAGING WITH No

FLOW

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 437 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78707 K FLOW/FUNCT IMAGE No

W/O DRUG

78708 K FLOW/FUNCT IMAGE No

W/DRUG

78709 K FLOW/FUNCT IMAGE No

MULTIPLE

78710 KIDNEY IMAGING (3D) No

78725 KIDNEY FUNCTION STUDY No

78730 URINARY BLADDER No

RETENTION

78740 URETERAL REFLUX STUDY No

78761 TESTICULAR IMAGING No

W/FLOW

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 438 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78799 GENITOURINARY No
NUCLEAR EXAM

78800 TUMOR IMAGING No

LIMITED AREA

78801 TUMOR IMAGING MULT No

AREAS

78802 TUMOR IMAGING No

WHOLE BODY

78803 TUMOR IMAGING (3D) No

78804 TUMOR IMAGING No

WHOLE BODY

78805 ABSCESS IMAGING LTD No

AREA

78806 ABSCESS IMAGING No

WHOLE BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 439 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78807 NUCLEAR No
LOCALIZATION/ABSCESS

78808 IV INJ RA DRUG DX STUDY No

78811 PET IMAGE LTD AREA Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78812 PET IMAGE SKULL-THIGH Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78813 PET IMAGE FULL BODY Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78814 PET IMAGE W/CT LMTD Yes For information about PA requirements, eviCore
eviCore
please contact eviCore, Inc. via FAX 888-
693-3210

78815 PET IMAGE W/CT SKULL- Yes For information about PA requirements, eviCore
eviCore
THIGH please contact eviCore, Inc. via FAX 888-
693-3210

78816 PET IMAGE W/CT FULL Yes For information about PA requirements, eviCore
eviCore
BODY please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 440 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

78999 NUCLEAR DIAGNOSTIC No

EXAM

79005 NUCLEAR RX ORAL ADMIN No

79101 NUCLEAR RX IV ADMIN No

79200 NUCLEAR RX INTRACAV No

ADMIN

79300 NUCLR RX INTERSTIT No

COLLOID

79403 HEMATOPOIETIC No
NUCLEAR TX

79440 NUCLEAR RX INTRA- No

ARTICULAR

79445 NUCLEAR RX INTRA- No

ARTERIAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 441 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

79999 NUCLEAR MEDICINE No

THERAPY

radiation oncology
77261 RADIATION THERAPY No
PLANNING

77262 RADIATION THERAPY No

PLANNING

77263 RADIATION THERAPY No

PLANNING

77280 SET RADIATION THERAPY No

FIELD

77285 SET RADIATION THERAPY No

FIELD

77290 SET RADIATION THERAPY No

FIELD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 442 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77293 RESPIRATOR MOTION No

MGMT SIMUL

77295 3-D RADIOTHERAPY PLAN No

77299 RADIATION THERAPY No

PLANNING

77300 RADIATION THERAPY No

DOSE PLAN

77301 RADIOTHERAPY DOSE Yes Please review the Well Sense Policy for Intensity Modulated Radiation Intensity Modulated
NH-IMRT
PLAN IMRT more details Therapy, Outpatient Radiation Therapy,
Inten Mod Outpatient (Eff 07/01/18)
Rad Ther

77306 TELETHX ISODOSE PLAN No

SIMPLE

77307 TELETHX ISODOSE PLAN No

CPLX

77316 BRACHYTX ISODOSE No

PLAN SIMPLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 443 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77317 BRACHYTX ISODOSE No

INTERMED

77318 BRACHYTX ISODOSE No

COMPLEX

77321 SPECIAL TELETX PORT No

PLAN

77331 SPECIAL RADIATION No

DOSIMETRY

77332 RADIATION TREATMENT No

AID(S)

77333 RADIATION TREATMENT No

AID(S)

77334 RADIATION TREATMENT No

AID(S)

77336 RADIATION PHYSICS No

CONSULT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 444 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77338 DESIGN MLC DEVICE FOR Yes Please review the Well Sense Policy for Intensity Modulated Radiation Intensity Modulated
NH-IMRT
IMRT more details Therapy, Outpatient Radiation Therapy,
Inten Mod Outpatient (Eff 07/01/18)
Rad Ther

77370 RADIATION PHYSICS No

CONSULT

77371 SRS MULTISOURCE Yes Provide clinical documentation supporting

IQ -
rationale for request (e.g., notes, lab
Neurosurgery values, X-rays, etc.)

77372 SRS LINEAR BASED Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
more details 11/01/18)
Neurosurgery

77373 SBRT DELIVERY No

77385 NTSTY MODUL RAD TX Yes Please review the Well Sense Policy for Intensity Modulated Radiation Intensity Modulated
NH-IMRT
DLVR SMPL more details Therapy, Outpatient Radiation Therapy,
Inten Mod Outpatient (Eff 07/01/18)
Rad Ther

77386 NTSTY MODUL RAD TX Yes Please review the Well Sense Policy for Intensity Modulated Radiation Intensity Modulated
NH-IMRT
DLVR CPLX more details Therapy, Outpatient Radiation Therapy,
Inten Mod Outpatient (Eff 07/01/18)
Rad Ther

77387 GUIDANCE FOR RADIAJ No

TX DLVR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 445 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77399 EXTERNAL RADIATION No

DOSIMETRY

77401 RADIATION TREATMENT No

DELIVERY

77402 RADIATION TREATMENT No

DELIVERY

77407 RADIATION TREATMENT No

DELIVERY

77412 RADIATION TREATMENT No

DELIVERY

77417 RADIOLOGY PORT No

IMAGES(S)

77422 NEUTRON BEAM TX No

SIMPLE

77423 NEUTRON BEAM TX No

COMPLEX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 446 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77424 IO RAD TX DELIVERY BY X- No

RAY

77425 IO RAD TX DELIVER BY No

ELCTRNS

77427 RADIATION TX No
MANAGEMENT X5

77431 RADIATION THERAPY No

MANAGEMENT

77432 STEREOTACTIC Yes

IQ -
RADIATION TRMT
Neurosurgery

77435 SBRT MANAGEMENT No

77469 IO RADIATION TX No
MANAGEMENT

77470 SPECIAL RADIATION No

TREATMENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 447 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77499 RADIATION THERAPY No

MANAGEMENT

77520 PROTON TRMT SIMPLE Yes* InterQual® criteria used. *Will be covered
NH-IQ-
W/O COMP only when performed in the Outpatient
Radiation setting.
Therapy

77522 PROTON TRMT SIMPLE Yes* InterQual® criteria used. *Will be covered
NH-IQ-
W/COMP only when performed in the Outpatient
Radiation setting.
Therapy

77523 PROTON TRMT Yes* InterQual® criteria used. *Will be covered

NH-IQ-
INTERMEDIATE only when performed in the Outpatient
Radiation setting.
Therapy

77525 PROTON TREATMENT Yes* InterQual® criteria used. *Will be covered

NH-IQ-
COMPLEX only when performed in the Outpatient
Radiation setting.
Therapy

77600 HYPERTHERMIA No
TREATMENT

77605 HYPERTHERMIA No
TREATMENT

77610 HYPERTHERMIA No
TREATMENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 448 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77615 HYPERTHERMIA No
TREATMENT

77620 HYPERTHERMIA No
TREATMENT

77750 INFUSE RADIOACTIVE No

MATERIALS

77761 APPLY INTRCAV RADIAT No

SIMPLE

77762 APPLY INTRCAV RADIAT No

INTERM

77763 APPLY INTRCAV RADIAT No

COMPL

77767 HDR RDNCL SKN SURF No

BRACHYTX

77768 HDR RDNCL SKN SURF No

BRACHYTX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 449 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77770 HDR RDNCL NTRSTL/ICAV No

BRCHTX

77771 HDR RDNCL NTRSTL/ICAV No

BRCHTX

77772 HDR RDNCL NTRSTL/ICAV No

BRCHTX

77778 APPLY INTERSTIT RADIAT No

COMPL

77789 APPLY SURF LDR No

RADIONUCLIDE

77790 RADIATION HANDLING No

77799 RADIUM/RADIOISOTOPE No
THERAPY

radiologic guidance

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 450 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77001 FLUOROGUIDE FOR VEIN No

DEVICE

77002 NEEDLE LOCALIZATION No

BY XRAY

77003 FLUOROGUIDE FOR SPINE No

INJECT

77011 CT SCAN FOR Yes For information about PA requirements, eviCore

eviCore
LOCALIZATION please contact eviCore, Inc. via FAX 888-
693-3210

77012 CT SCAN FOR NEEDLE Yes For information about PA requirements, eviCore
eviCore
BIOPSY please contact eviCore, Inc. via FAX 888-
693-3210

77013 CT GUIDE FOR TISSUE Yes For information about PA requirements, eviCore
eviCore
ABLATION please contact eviCore, Inc. via FAX 888-
693-3210

77014 CT SCAN FOR THERAPY No

GUIDE

77021 MR GUIDANCE FOR Yes For information about PA requirements, eviCore

eviCore
NEEDLE PLACE please contact eviCore, Inc. via FAX 888-
693-3210

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 451 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

77022 MRI FOR TISSUE Yes For information about PA requirements, eviCore
eviCore
ABLATION please contact eviCore, Inc. via FAX 888-
693-3210

Codes for Surgery

female genital system
56405 I & D OF No
VULVA/PERINEUM

56420 DRAINAGE OF GLAND No

ABSCESS

56440 SURGERY FOR VULVA No

LESION

56441 LYSIS OF LABIAL LESION(S) No

56442 HYMENOTOMY No

56501 DESTROY VULVA LESIONS No

SIM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 452 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

56515 DESTROY VULVA No

LESION/S COMPL

56605 BIOPSY OF No
VULVA/PERINEUM

56606 BIOPSY OF No
VULVA/PERINEUM

56620 PARTIAL REMOVAL OF No

VULVA

56625 COMPLETE REMOVAL OF Yes This policy applies to this code when billed
VULVA with DX code(s) F64.1-F64.9 and/or
Z87.890

56630 EXTENSIVE VULVA No

SURGERY

56631 EXTENSIVE VULVA No

SURGERY

56632 EXTENSIVE VULVA No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 453 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

56633 EXTENSIVE VULVA No

SURGERY

56634 EXTENSIVE VULVA No

SURGERY

56637 EXTENSIVE VULVA No

SURGERY

56640 EXTENSIVE VULVA No

SURGERY

56700 PARTIAL REMOVAL OF No

HYMEN

56740 REMOVE VAGINA GLAND No

LESION

56800 REPAIR OF VAGINA Yes

56805 REPAIR CLITORIS Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 454 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

56810 REPAIR OF PERINEUM Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

56820 EXAM OF VULVA No

W/SCOPE

56821 EXAM/BIOPSY OF VULVA No

W/SCOPE

57000 EXPLORATION OF VAGINA No

57010 DRAINAGE OF PELVIC No

ABSCESS

57020 DRAINAGE OF PELVIC No

FLUID

57022 I & D VAGINAL No

HEMATOMA PP

57023 I & D VAG HEMATOMA No

NON-OB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 455 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57061 DESTROY VAG LESIONS No

SIMPLE

57065 DESTROY VAG LESIONS No

COMPLEX

57100 BIOPSY OF VAGINA No

57105 BIOPSY OF VAGINA No

57106 REMOVE VAGINA WALL Yes This policy applies to this code when billed
IQ - GYN
PARTIAL with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

57107 REMOVE VAGINA TISSUE Yes This policy applies to this code when billed
IQ - GYN
PART with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

57109 VAGINECTOMY PARTIAL Yes Provide clinical documentation supporting

IQ - GYN
W/NODES rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

57110 REMOVE VAGINA WALL Yes This policy applies to this code when billed
IQ - GYN
COMPLETE with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 456 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57111 REMOVE VAGINA TISSUE Yes This policy applies to this code when billed
IQ - GYN
COMPL with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

57112 VAGINECTOMY No
W/NODES COMPL

57120 CLOSURE OF VAGINA No

57130 REMOVE VAGINA LESION No

57135 REMOVE VAGINA LESION No

57150 TREAT VAGINA INFECTION No

57155 INSERT UTERI No

TANDEM/OVOIDS

57156 INS VAG BRACHYTX No

DEVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 457 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57160 INSERT PESSARY/OTHER No

DEVICE

57170 FITTING OF No
DIAPHRAGM/CAP

57180 TREAT VAGINAL No

BLEEDING

57200 REPAIR OF VAGINA No

57210 REPAIR No
VAGINA/PERINEUM

57220 REVISION OF URETHRA No

57230 REPAIR OF URETHRAL No

LESION

57240 REPAIR BLADDER & No

VAGINA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 458 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57250 REPAIR RECTUM & No

VAGINA

57260 REPAIR OF VAGINA No

57265 EXTENSIVE REPAIR OF No

VAGINA

57267 INSERT MESH/PELVIC FLR No

ADDON

57268 REPAIR OF BOWEL BULGE No

57270 REPAIR OF BOWEL POUCH No

57280 SUSPENSION OF VAGINA No

57282 COLPOPEXY No
EXTRAPERITONEAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 459 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57283 COLPOPEXY No
INTRAPERITONEAL

57284 REPAIR PARAVAG DEFECT No

OPEN

57285 REPAIR PARAVAG DEFECT No

VAG

57287 REVISE/REMOVE SLING No

REPAIR

57288 REPAIR BLADDER DEFECT Yes InterQual® criteria used. Provide clinical
IQ - GU
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

57289 REPAIR BLADDER & Yes InterQual® criteria used. Provide clinical
IQ - GU
VAGINA documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

57291 CONSTRUCTION OF Yes This policy applies to this code when billed
VAGINA with DX code(s) F64.1-F64.9 and/or
Z87.890

57292 CONSTRUCT VAGINA Yes This policy applies to this code when billed
WITH GRAFT with DX code(s) F64.1-F64.9 and/or
Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 460 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57295 REVISE VAG GRAFT VIA No

VAGINA

57296 REVISE VAG GRAFT OPEN No

ABD

57300 REPAIR RECTUM-VAGINA No

FISTULA

57305 REPAIR RECTUM-VAGINA No

FISTULA

57307 FISTULA REPAIR & No

COLOSTOMY

57308 FISTULA REPAIR No

TRANSPERINE

57310 REPAIR No
URETHROVAGINAL
LESION

57311 REPAIR No
URETHROVAGINAL
LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 461 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57320 REPAIR BLADDER-VAGINA No

LESION

57330 REPAIR BLADDER-VAGINA No

LESION

57335 REPAIR VAGINA Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

57400 DILATION OF VAGINA No

57410 PELVIC EXAMINATION No

57415 REMOVE VAGINAL No

FOREIGN BODY

57420 EXAM OF VAGINA No

W/SCOPE

57421 EXAM/BIOPSY OF VAG No

W/SCOPE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 462 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57423 REPAIR PARAVAG DEFECT No

LAP

57425 LAPAROSCOPY SURG No

COLPOPEXY

57426 REVISE PROSTH VAG Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
GRAFT LAP more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

57452 EXAM OF CERVIX No

W/SCOPE

57454 BX/CURETT OF CERVIX No

W/SCOPE

57455 BIOPSY OF CERVIX No

W/SCOPE

57456 ENDOCERV CURETTAGE No

W/SCOPE

57460 BX OF CERVIX W/SCOPE No

LEEP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 463 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57461 CONZ OF CERVIX No

W/SCOPE LEEP

57500 BIOPSY OF CERVIX No

57505 ENDOCERVICAL No
CURETTAGE

57510 CAUTERIZATION OF No
CERVIX

57511 CRYOCAUTERY OF CERVIX No

57513 LASER SURGERY OF No

CERVIX

57520 CONIZATION OF CERVIX No

57522 CONIZATION OF CERVIX No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 464 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57530 REMOVAL OF CERVIX No

57531 REMOVAL OF CERVIX No

RADICAL

57540 REMOVAL OF RESIDUAL No

CERVIX

57545 REMOVE CERVIX/REPAIR No

PELVIS

57550 REMOVAL OF RESIDUAL No

CERVIX

57555 REMOVE CERVIX/REPAIR No

VAGINA

57556 REMOVE CERVIX REPAIR No

BOWEL

57558 D&C OF CERVICAL STUMP No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 465 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

57700 REVISION OF CERVIX No

57720 REVISION OF CERVIX No

57800 DILATION OF CERVICAL No

CANAL

58100 BIOPSY OF UTERUS No

LINING

58110 BX DONE No
W/COLPOSCOPY ADD-ON

58120 DILATION AND No* *PA req'd if performed as elective proc in

CURETTAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58140 MYOMECTOMY ABDOM No

METHOD

58145 MYOMECTOMY VAG No

METHOD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 466 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58146 MYOMECTOMY ABDOM No

COMPLEX

58150 TOTAL HYSTERECTOMY Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58152 TOTAL HYSTERECTOMY Yes Provide clinical documentation supporting

IQ - GYN
rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

58180 PARTIAL HYSTERECTOMY Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58200 EXTENSIVE Yes Provide clinical documentation supporting

IQ - GYN
HYSTERECTOMY rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

58210 EXTENSIVE No
HYSTERECTOMY

58240 REMOVAL OF PELVIS No

CONTENTS

58260 VAGINAL HYSTERECTOMY Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 467 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58262 VAG HYST INCLUDING T/O Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58263 VAG HYST W/T/O & VAG Yes InterQual® criteria used. Provide clinical
IQ - GYN
REPAIR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

58267 VAG HYST W/URINARY Yes Provide clinical documentation supporting

IQ - GYN
REPAIR rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

58270 VAG HYST Yes InterQual® criteria used. Provide clinical

IQ - GYN
W/ENTEROCELE REPAIR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

58275 HYSTERECTOMY/REVISE Yes This policy applies to this code when billed
IQ - GYN
VAGINA with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58280 HYSTERECTOMY/REVISE Yes Provide clinical documentation supporting

IQ - GYN
VAGINA rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

58285 EXTENSIVE No
HYSTERECTOMY

58290 VAG HYST COMPLEX Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 468 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58291 VAG HYST INCL T/O Yes This policy applies to this code when billed
IQ - GYN
COMPLEX with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58292 VAG HYST T/O & REPAIR Yes InterQual® criteria used. Provide clinical
IQ - GYN
COMPL documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

58293 VAG HYST W/URO Yes Provide clinical documentation supporting

IQ - GYN
REPAIR COMPL rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

58294 VAG HYST Yes InterQual® criteria used. Provide clinical

IQ - GYN
W/ENTEROCELE COMPL documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

58300 INSERT INTRAUTERINE No

DEVICE

58301 REMOVE INTRAUTERINE No

DEVICE

58321 ARTIFICIAL No
INSEMINATION

58322 ARTIFICIAL No
INSEMINATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 469 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58323 SPERM WASHING No

58340 CATHETER FOR No

HYSTEROGRAPHY

58345 REOPEN FALLOPIAN TUBE No

58346 INSERT HEYMAN UTERI No

CAPSULE

58350 REOPEN FALLOPIAN TUBE No

58353 ENDOMETR ABLATE No

THERMAL

58356 ENDOMETRIAL No
CRYOABLATION

58400 SUSPENSION OF UTERUS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 470 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58410 SUSPENSION OF UTERUS No

58520 REPAIR OF RUPTURED No

UTERUS

58540 REVISION OF UTERUS No

58541 LSH UTERUS 250 G OR Yes This policy applies to this code when billed
IQ - GYN
LESS with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58542 LSH W/T/O UT 250 G OR Yes This policy applies to this code when billed
IQ - GYN
LESS with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58543 LSH UTERUS ABOVE 250 G Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58544 LSH W/T/O UTERUS Yes This policy applies to this code when billed
IQ - GYN
ABOVE 250 G with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58545 LAPAROSCOPIC No
MYOMECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 471 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58546 LAPARO-MYOMECTOMY No
COMPLEX

58548 LAP RADICAL HYST No

58550 LAPARO-ASST VAG Yes This policy applies to this code when billed
IQ - GYN
HYSTERECTOMY with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58552 LAPARO-VAG HYST INCL Yes This policy applies to this code when billed
IQ - GYN
T/O with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58553 LAPARO-VAG HYST Yes This policy applies to this code when billed
IQ - GYN
COMPLEX with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58554 LAPARO-VAG HYST Yes This policy applies to this code when billed
IQ - GYN
W/T/O COMPL with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58555 HYSTEROSCOPY DX SEP No* *PA req'd if performed as elective proc in

PROC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58558 HYSTEROSCOPY BIOPSY No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 472 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58559 HYSTEROSCOPY LYSIS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58560 HYSTEROSCOPY RESECT No* *PA req'd if performed as elective proc in

SEPTUM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58561 HYSTEROSCOPY REMOVE No* *PA req'd if performed as elective proc in

MYOMA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58562 HYSTEROSCOPY REMOVE No* *PA req'd if performed as elective proc in

FB the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58563 HYSTEROSCOPY No* *PA req'd if performed as elective proc in

ABLATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58565 HYSTEROSCOPY No
STERILIZATION

58570 TLH UTERUS 250 G OR Yes This policy applies to this code when billed
IQ - GYN
LESS with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58571 TLH W/T/O 250 G OR LESS Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 473 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58572 TLH UTERUS OVER 250 G Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58573 TLH W/T/O UTERUS Yes This policy applies to this code when billed
IQ - GYN
OVER 250 G with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58578 LAPARO PROC UTERUS No

58579 HYSTEROSCOPE No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58600 DIVISION OF FALLOPIAN No

TUBE

58605 DIVISION OF FALLOPIAN No

TUBE

58611 LIGATE OVIDUCT(S) ADD- No

ON

58615 OCCLUDE FALLOPIAN No

TUBE(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 474 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58660 LAPAROSCOPY LYSIS No

58661 LAPAROSCOPY REMOVE Yes This policy applies to this code when billed
IQ - GYN
ADNEXA with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58662 LAPAROSCOPY EXCISE No* *PA req'd if performed as elective proc in

LESIONS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

58670 LAPAROSCOPY TUBAL No

CAUTERY

58671 LAPAROSCOPY TUBAL No

BLOCK

58672 LAPAROSCOPY No
FIMBRIOPLASTY

58673 LAPAROSCOPY No
SALPINGOSTOMY

58679 LAPARO PROC OVIDUCT- No

OVARY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 475 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58700 REMOVAL OF FALLOPIAN No

TUBE

58720 REMOVAL OF Yes This policy applies to this code when billed
IQ - GYN
OVARY/TUBE(S) with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

58740 ADHESIOLYSIS TUBE No

OVARY

58750 REPAIR OVIDUCT No

58752 REVISE OVARIAN TUBE(S) No

58760 FIMBRIOPLASTY No

58770 CREATE NEW TUBAL No

OPENING

58800 DRAINAGE OF OVARIAN No

CYST(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 476 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58805 DRAINAGE OF OVARIAN No

CYST(S)

58820 DRAIN OVARY ABSCESS No

OPEN

58822 DRAIN OVARY ABSCESS No

PERCUT

58825 TRANSPOSITION No
OVARY(S)

58900 BIOPSY OF OVARY(S) No

58920 PARTIAL REMOVAL OF No

OVARY(S)

58925 REMOVAL OF OVARIAN No

CYST(S)

58940 REMOVAL OF OVARY(S) Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 477 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58943 REMOVAL OF OVARY(S) No

58950 RESECT OVARIAN No

MALIGNANCY

58951 RESECT OVARIAN No

MALIGNANCY

58952 RESECT OVARIAN No

MALIGNANCY

58953 TAH RAD DISSECT FOR No

DEBULK

58954 TAH RAD DEBULK/LYMPH No

REMOVE

58956 BSO OMENTECTOMY No

W/TAH

58957 RESECT RECURRENT GYN No

MAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 478 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

58958 RESECT RECUR GYN MAL No

W/LYM

58960 EXPLORATION OF No
ABDOMEN

58970 RETRIEVAL OF OOCYTE No

58974 TRANSFER OF EMBRYO No

58976 TRANSFER OF EMBRYO No

58999 GENITAL SURGERY No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

auditory system
69000 DRAIN EXTERNAL EAR No
LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 479 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69005 DRAIN EXTERNAL EAR No

LESION

69020 DRAIN OUTER EAR CANAL No

LESION

69090 PIERCE EARLOBES No

69100 BIOPSY OF EXTERNAL EAR No

69105 BIOPSY OF EXTERNAL No

EAR CANAL

69110 REMOVE EXTERNAL EAR No

PARTIAL

69120 REMOVAL OF EXTERNAL No

EAR

69140 REMOVE EAR CANAL No

LESION(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 480 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69145 REMOVE EAR CANAL No

LESION(S)

69150 EXTENSIVE EAR CANAL No

SURGERY

69155 EXTENSIVE EAR/NECK No

SURGERY

69200 CLEAR OUTER EAR CANAL No

69205 CLEAR OUTER EAR CANAL No

69209 REMOVE IMPACTED EAR No

WAX UNI

69210 REMOVE IMPACTED EAR No

WAX UNI

69220 CLEAN OUT MASTOID No

CAVITY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 481 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69222 CLEAN OUT MASTOID No

CAVITY

69300 REVISE EXTERNAL EAR Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

69310 REBUILD OUTER EAR No

CANAL

69320 REBUILD OUTER EAR No

CANAL

69399 OUTER EAR SURGERY No

PROCEDURE

69420 INCISION OF EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
ages 0-18 yrs. Otherwise, InterQual®
Surg criteria used. Will be covered only when
performed in the Outpatient setting.

69421 INCISION OF EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
ages 0-18 yrs. Otherwise, InterQual®
Surg criteria used. Will be covered only when
performed in the Outpatient setting.

69424 REMOVE VENTILATING No

TUBE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 482 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69433 CREATE EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
OPENING ages 0-18 yrs. Otherwise, InterQual®
Surg criteria used. Will be covered only when
performed in the Outpatient setting.

69436 CREATE EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
OPENING ages 0-18 yrs. Otherwise, InterQual®
Surg criteria used. Will be covered only when
performed in the Outpatient setting.

69440 EXPLORATION OF No
MIDDLE EAR

69450 EARDRUM REVISION No

69501 MASTOIDECTOMY No

69502 MASTOIDECTOMY No

69505 REMOVE MASTOID No

STRUCTURES

69511 EXTENSIVE MASTOID No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 483 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69530 EXTENSIVE MASTOID No

SURGERY

69535 REMOVE PART OF No

TEMPORAL BONE

69540 REMOVE EAR LESION No

69550 REMOVE EAR LESION No

69552 REMOVE EAR LESION No

69554 REMOVE EAR LESION No

69601 MASTOID SURGERY No

REVISION

69602 MASTOID SURGERY No

REVISION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 484 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69603 MASTOID SURGERY No

REVISION

69604 MASTOID SURGERY No

REVISION

69605 MASTOID SURGERY No

REVISION

69610 REPAIR OF EARDRUM No

69620 REPAIR OF EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
ages 0-18 yrs. Otherwise, Medically
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69631 REPAIR EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69632 REBUILD EARDRUM Yes* *NOTE: This code does NOT require PA for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically 11/01/18)
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69633 REBUILD EARDRUM Yes* *NOTE: This code does NOT require PA for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically 11/01/18)
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 485 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69635 REPAIR EARDRUM Yes* *NOTE: This code does NOT require PA for
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69636 REBUILD EARDRUM Yes* *NOTE: This code does NOT require PA for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically 11/01/18)
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69637 REBUILD EARDRUM Yes* *NOTE: This code does NOT require PA for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
STRUCTURES ages 0-18 yrs. Otherwise, Medically 11/01/18)
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69641 REVISE MIDDLE EAR & Yes *NOTE: This code does NOT require PA for
NH-IQ - ENT
MASTOID ages 0-18 yrs. Otherwise, Medically
Surg Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
69642 REVISE MIDDLE EAR & No
MASTOID

69643 REVISE MIDDLE EAR & No

MASTOID

69644 REVISE MIDDLE EAR & No

MASTOID

69645 REVISE MIDDLE EAR & No

MASTOID

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 486 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69646 REVISE MIDDLE EAR & No

MASTOID

69650 RELEASE MIDDLE EAR No

BONE

69660 REVISE MIDDLE EAR BONE No

69661 REVISE MIDDLE EAR BONE No

69662 REVISE MIDDLE EAR BONE No

69666 REPAIR MIDDLE EAR No

STRUCTURES

69667 REPAIR MIDDLE EAR No

STRUCTURES

69670 REMOVE MASTOID AIR No

CELLS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 487 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69676 REMOVE MIDDLE EAR No

NERVE

69700 CLOSE MASTOID FISTULA No

69710 IMPLANT/REPLACE Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
HEARING AID more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

69711 REMOVE/REPAIR Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
HEARING AID more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

69714 IMPLANT TEMPLE BONE Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
W/STIMUL more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

69715 TEMPLE BNE IMPLNT Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
W/STIMULAT more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

69717 TEMPLE BONE IMPLANT Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
REVISION more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

69718 REVISE TEMPLE BONE Yes Please review the Well Sense Policy for Implantable Bone-Conduction (Bone- Implantable Bone-Conduction Implantable Bone-
NH-Cochlear
IMPLANT more details Anchored) Hearing Aids (Bone-Anchored) Hearing Conduction (Bone-
Implants & Aids ( Eff 08/01/18) Anchored) Hearing Aids
BAHA
(Eff 08/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 488 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69720 RELEASE FACIAL NERVE No

69725 RELEASE FACIAL NERVE No

69740 REPAIR FACIAL NERVE No

69745 REPAIR FACIAL NERVE No

69799 MIDDLE EAR SURGERY No

PROCEDURE

69801 INCISE INNER EAR No

69805 EXPLORE INNER EAR No

69806 EXPLORE INNER EAR No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 489 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69820 ESTABLISH INNER EAR No

WINDOW

69840 REVISE INNER EAR No

WINDOW

69905 REMOVE INNER EAR No

69910 REMOVE INNER EAR & No

MASTOID

69915 INCISE INNER EAR NERVE No

69930 IMPLANT COCHLEAR Yes* Please review BMCHP criteria for details. Cochlear Implants Cochlear Implants ( Eff
NH-Cochlear
DEVICE *Will be covered only when performed in 06/01/18)
Implants & the Outpatient setting.
BAHA

69949 INNER EAR SURGERY No

PROCEDURE

69950 INCISE INNER EAR NERVE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 490 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

69955 RELEASE FACIAL NERVE No

69960 RELEASE INNER EAR No

CANAL

69970 REMOVE INNER EAR No

LESION

69979 TEMPORAL BONE No

SURGERY

cardiovascular system
33010 DRAINAGE OF HEART SAC No

33011 REPEAT DRAINAGE OF No

HEART SAC

33015 INCISION OF HEART SAC No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 491 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33020 INCISION OF HEART SAC No

33025 INCISION OF HEART SAC No

33030 PARTIAL REMOVAL OF No

HEART SAC

33031 PARTIAL REMOVAL OF No

HEART SAC

33050 RESECT HEART SAC No

LESION

33120 REMOVAL OF HEART No

LESION

33130 REMOVAL OF HEART No

LESION

33140 HEART REVASCULARIZE No

(TMR)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 492 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33141 HEART TMR W/OTHER No

PROCEDURE

33202 INSERT EPICARD ELTRD Yes InterQual® criteria used. Provide clinical
NH-IQ -
OPEN documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33203 INSERT EPICARD ELTRD Yes* InterQual® criteria used. *Will be covered
NH-IQ -
ENDO only when performed in the Outpatient
Cardiac Surg setting.

33206 INSERT HEART PM ATRIAL No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33207 INSERT HEART PM Yes* InterQual® criteria used. *Will be covered

NH-IQ -
VENTRICULAR only when performed in the Outpatient
Cardiac Surg setting.

33208 INSRT HEART PM ATRIAL Yes* InterQual® criteria used. *Will be covered
NH-IQ -
& VENT only when performed in the Outpatient
Cardiac Surg setting.

33210 INSERT ELECTRD/PM No

CATH SNGL

33211 INSERT CARD No

ELECTRODES DUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 493 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33212 INSERT PULSE GEN SNGL No* *PA req'd if performed as elective proc in
LEAD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33213 INSERT PULSE GEN DUAL Yes* InterQual® criteria used. *Will be covered
NH-IQ -
LEADS only when performed in the Outpatient
Cardiac Surg setting.

33214 UPGRADE OF No* *PA req'd if performed as elective proc in

NH-IQ -
PACEMAKER SYSTEM the Inpatient setting; incl all clinical
Cardiac Surg documentation that supports the need for
inpatient level of care.

33215 REPOSITION PACING- No

DEFIB LEAD

33216 INSERT 1 ELECTRODE PM- No* *PA req'd if performed as elective proc in
DEFIB the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33217 INSERT 2 ELECTRODE PM- No* *PA req'd if performed as elective proc in
DEFIB the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33218 REPAIR LEAD PACE-DEFIB No

ONE

33220 REPAIR LEAD PACE-DEFIB No

DUAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 494 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33221 INSERT PULSE GEN MULT No* *PA req'd if performed as elective proc in
LEADS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33222 RELOCATION POCKET No

PACEMAKER

33223 RELOCATE POCKET FOR No

DEFIB

33224 INSERT PACING LEAD & Yes* InterQual® criteria used. *Will be covered
NH-IQ -
CONNECT only when performed in the Outpatient
Cardiac Surg setting.

33225 L VENTRIC PACING LEAD Yes* InterQual® criteria used. *Will be covered
NH-IQ -
ADD-ON only when performed in the Outpatient
Cardiac Surg setting.

33226 REPOSITION L VENTRIC No

LEAD

33227 REMOVE&REPLACE PM No* *PA req'd if performed as elective proc in

GEN SINGL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33228 REMV&REPLC PM GEN No* *PA req'd if performed as elective proc in

DUAL LEAD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 495 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33229 REMV&REPLC PM GEN No* *PA req'd if performed as elective proc in

MULT LEADS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33230 INSRT PULSE GEN Yes InterQual® criteria used. Provide clinical
NH-IQ -
W/DUAL LEADS documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33231 INSRT PULSE GEN No

W/MULT LEADS

33233 REMOVAL OF PM No
GENERATOR

33234 REMOVAL OF No
PACEMAKER SYSTEM

33235 REMOVAL PACEMAKER No

ELECTRODE

33236 REMOVE No
ELECTRODE/THORACOTO
MY

33237 REMOVE No
ELECTRODE/THORACOTO
MY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 496 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33238 REMOVE No
ELECTRODE/THORACOTO
MY

33240 INSRT PULSE GEN Yes InterQual® criteria used. Provide clinical
NH-IQ -
W/SINGL LEAD documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33241 REMOVE PULSE No* *PA req'd if performed as elective proc in

GENERATOR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33243 REMOVE No
ELTRD/THORACOTOMY

33244 REMOVE ELCTRD No

TRANSVENOUSLY

33249 INSJ/RPLCMT DEFIB No* *PA req'd if performed as elective proc in

W/LEAD(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33250 ABLATE HEART No

DYSRHYTHM FOCUS

33251 ABLATE HEART No

DYSRHYTHM FOCUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 497 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33254 ABLATE ATRIA LMTD No

33255 ABLATE ATRIA W/O No

BYPASS EXT

33256 ABLATE ATRIA W/BYPASS No

EXTEN

33257 ABLATE ATRIA LMTD ADD- No

ON

33258 ABLATE ATRIA X10SV No

ADD-ON

33259 ABLATE ATRIA W/BYPASS No

ADD-ON

33261 ABLATE HEART No

DYSRHYTHM FOCUS

33262 RMVL& REPLC PULSE No* *PA req'd if performed as elective proc in
GEN 1 LEAD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 498 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33263 RMVL & RPLCMT DFB No* *PA req'd if performed as elective proc in
GEN 2 LEAD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33264 RMVL & RPLCMT DFB No* *PA req'd if performed as elective proc in
GEN MLT LD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

33265 ABLATE ATRIA LMTD No

ENDO

33266 ABLATE ATRIA X10SV No

ENDO

33270 INS/REP SUBQ No

DEFIBRILLATOR

33271 INSJ SUBQ IMPLTBL DFB No

ELCTRD

33272 RMVL OF SUBQ No

DEFIBRILLATOR

33273 REPOS PREV IMPLTBL No

SUBQ DFB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 499 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33285 INSJ SUBQ CAR RHYTHM Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
MNTR more details (Excluding Holter Monitors) Monitors (Excluding Holter
Monitors) ( Eff 01/01/19)

33300 REPAIR OF HEART No

WOUND

33305 REPAIR OF HEART No

WOUND

33310 EXPLORATORY HEART No

SURGERY

33315 EXPLORATORY HEART No

SURGERY

33320 REPAIR MAJOR BLOOD No

VESSEL(S)

33321 REPAIR MAJOR VESSEL No

33322 REPAIR MAJOR BLOOD No

VESSEL(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 500 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33330 INSERT MAJOR VESSEL No

GRAFT

33335 INSERT MAJOR VESSEL No

GRAFT

33340 PERQ CLSR TCAT L ATR Yes

APNDGE

33361 REPLACE AORTIC VALVE No

PERQ

33362 REPLACE AORTIC VALVE No

OPEN

33363 REPLACE AORTIC VALVE No

OPEN

33364 REPLACE AORTIC VALVE No

OPEN

33365 REPLACE AORTIC VALVE No

OPEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 501 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33366 TRCATH REPLACE AORTIC No

VALVE

33367 REPLACE AORTIC VALVE No

W/BYP

33368 REPLACE AORTIC VALVE No

W/BYP

33369 REPLACE AORTIC VALVE No

W/BYP

33400 REPAIR OF AORTIC VALVE No

33401 VALVULOPLASTY OPEN No

33403 VALVULOPLASTY W/CP No

BYPASS

33404 PREPARE HEART-AORTA No

CONDUIT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 502 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33405 REPLACEMENT AORTIC No

VALVE OPN

33406 REPLACEMENT AORTIC No

VALVE OPN

33410 REPLACEMENT AORTIC No

VALVE OPN

33411 REPLACEMENT OF No
AORTIC VALVE

33412 REPLACEMENT OF No
AORTIC VALVE

33413 REPLACEMENT OF No
AORTIC VALVE

33414 REPAIR OF AORTIC VALVE No

33415 REVISION SUBVALVULAR No

TISSUE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 503 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33416 REVISE VENTRICLE No

MUSCLE

33417 REPAIR OF AORTIC VALVE No

33418 REPAIR TCAT MITRAL No

VALVE

33419 REPAIR TCAT MITRAL No

VALVE

33420 REVISION OF MITRAL No

VALVE

33422 REVISION OF MITRAL No

VALVE

33425 REPAIR OF MITRAL VALVE No

33426 REPAIR OF MITRAL VALVE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 504 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33427 REPAIR OF MITRAL VALVE No

33430 REPLACEMENT OF No
MITRAL VALVE

33460 REVISION OF TRICUSPID No

VALVE

33463 VALVULOPLASTY No
TRICUSPID

33464 VALVULOPLASTY No
TRICUSPID

33465 REPLACE TRICUSPID No

VALVE

33468 REVISION OF TRICUSPID No

VALVE

33470 REVISION OF No
PULMONARY VALVE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 505 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33471 VALVOTOMY No
PULMONARY VALVE

33474 REVISION OF No
PULMONARY VALVE

33475 REPLACEMENT No
PULMONARY VALVE

33476 REVISION OF HEART No

CHAMBER

33477 IMPLANT TCAT PULM No

VLV PERQ

33478 REVISION OF HEART No

CHAMBER

33496 REPAIR PROSTH VALVE No

CLOT

33500 REPAIR HEART VESSEL No

FISTULA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 506 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33501 REPAIR HEART VESSEL No

FISTULA

33502 CORONARY ARTERY No

CORRECTION

33503 CORONARY ARTERY No

GRAFT

33504 CORONARY ARTERY No

GRAFT

33505 REPAIR ARTERY No

W/TUNNEL

33506 REPAIR ARTERY No

TRANSLOCATION

33507 REPAIR ART INTRAMURAL No

33508 ENDOSCOPIC VEIN No

HARVEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 507 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33510 CABG VEIN SINGLE No

33511 CABG VEIN TWO No

33512 CABG VEIN THREE No

33513 CABG VEIN FOUR No

33514 CABG VEIN FIVE No

33516 CABG VEIN SIX OR MORE No

33517 CABG ARTERY-VEIN No

SINGLE

33518 CABG ARTERY-VEIN TWO No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 508 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33519 CABG ARTERY-VEIN No

THREE

33521 CABG ARTERY-VEIN FOUR No

33522 CABG ARTERY-VEIN FIVE No

33523 CABG ART-VEIN SIX OR No

MORE

33530 CORONARY ARTERY No

BYPASS/REOP

33533 CABG ARTERIAL SINGLE No

33534 CABG ARTERIAL TWO No

33535 CABG ARTERIAL THREE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 509 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33536 CABG ARTERIAL FOUR OR No

MORE

33542 REMOVAL OF HEART No

LESION

33545 REPAIR OF HEART No

DAMAGE

33548 RESTORE/REMODEL No
VENTRICLE

33572 OPEN CORONARY No

ENDARTERECTOMY

33600 CLOSURE OF VALVE No

33602 CLOSURE OF VALVE No

33606 ANASTOMOSIS/ARTERY- No
AORTA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 510 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33608 REPAIR ANOMALY No

W/CONDUIT

33610 REPAIR BY ENLARGEMENT No

33611 REPAIR DOUBLE No

VENTRICLE

33612 REPAIR DOUBLE No

VENTRICLE

33615 REPAIR MODIFIED No

FONTAN

33617 REPAIR SINGLE VENTRICLE No

33619 REPAIR SINGLE VENTRICLE No

33620 APPLY R&L PULM ART No

BANDS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 511 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33621 TRANSTHOR CATH FOR No

STENT

33622 REDO COMPL CARDIAC No

ANOMALY

33641 REPAIR HEART SEPTUM No

DEFECT

33645 REVISION OF HEART No

VEINS

33647 REPAIR HEART SEPTUM No

DEFECTS

33660 REPAIR OF HEART No

DEFECTS

33665 REPAIR OF HEART No

DEFECTS

33670 REPAIR OF HEART No

CHAMBERS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 512 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33675 CLOSE MULT VSD No

33676 CLOSE MULT VSD No

W/RESECTION

33677 CL MULT VSD W/REM No

PUL BAND

33681 REPAIR HEART SEPTUM No

DEFECT

33684 REPAIR HEART SEPTUM No

DEFECT

33688 REPAIR HEART SEPTUM No

DEFECT

33690 REINFORCE PULMONARY No

ARTERY

33692 REPAIR OF HEART No

DEFECTS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 513 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33694 REPAIR OF HEART No

DEFECTS

33697 REPAIR OF HEART No

DEFECTS

33702 REPAIR OF HEART No

DEFECTS

33710 REPAIR OF HEART No

DEFECTS

33720 REPAIR OF HEART DEFECT No

33722 REPAIR OF HEART DEFECT No

33724 REPAIR VENOUS No

ANOMALY

33726 REPAIR PUL VENOUS No

STENOSIS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 514 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33730 REPAIR HEART-VEIN No

DEFECT(S)

33732 REPAIR HEART-VEIN No

DEFECT

33735 REVISION OF HEART No

CHAMBER

33736 REVISION OF HEART No

CHAMBER

33737 REVISION OF HEART No

CHAMBER

33750 MAJOR VESSEL SHUNT No

33755 MAJOR VESSEL SHUNT No

33762 MAJOR VESSEL SHUNT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 515 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33764 MAJOR VESSEL SHUNT & No

GRAFT

33766 MAJOR VESSEL SHUNT No

33767 MAJOR VESSEL SHUNT No

33768 CAVOPULMONARY No
SHUNTING

33770 REPAIR GREAT VESSELS No

DEFECT

33771 REPAIR GREAT VESSELS No

DEFECT

33774 REPAIR GREAT VESSELS No

DEFECT

33775 REPAIR GREAT VESSELS No

DEFECT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 516 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33776 REPAIR GREAT VESSELS No

DEFECT

33777 REPAIR GREAT VESSELS No

DEFECT

33778 REPAIR GREAT VESSELS No

DEFECT

33779 REPAIR GREAT VESSELS No

DEFECT

33780 REPAIR GREAT VESSELS No

DEFECT

33781 REPAIR GREAT VESSELS No

DEFECT

33782 NIKAIDOH PROC No

33783 NIKAIDOH PROC No

W/OSTIA IMPLT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 517 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33786 REPAIR ARTERIAL TRUNK No

33788 REVISION OF No
PULMONARY ARTERY

33800 AORTIC SUSPENSION No

33802 REPAIR VESSEL DEFECT No

33803 REPAIR VESSEL DEFECT No

33813 REPAIR SEPTAL DEFECT No

33814 REPAIR SEPTAL DEFECT No

33820 REVISE MAJOR VESSEL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 518 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33822 REVISE MAJOR VESSEL No

33824 REVISE MAJOR VESSEL No

33840 REMOVE AORTA No

CONSTRICTION

33845 REMOVE AORTA No

CONSTRICTION

33851 REMOVE AORTA No

CONSTRICTION

33852 REPAIR SEPTAL DEFECT No

33853 REPAIR SEPTAL DEFECT No

33860 ASCENDING AORTIC No

GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 519 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33863 ASCENDING AORTIC No

GRAFT

33864 ASCENDING AORTIC No

GRAFT

33870 TRANSVERSE AORTIC No

ARCH GRAFT

33875 THORACIC AORTIC GRAFT No

33877 THORACOABDOMINAL No
GRAFT

33880 ENDOVASC TAA REPR No

INCL SUBCL

33881 ENDOVASC TAA REPR No

W/O SUBCL

33883 INSERT ENDOVASC No

PROSTH TAA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 520 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33884 ENDOVASC PROSTH TAA No

ADD-ON

33886 ENDOVASC PROSTH No

DELAYED

33889 ARTERY No
TRANSPOSE/ENDOVAS
TAA

33891 CAR-CAR BP No
GRFT/ENDOVAS TAA

33910 REMOVE LUNG ARTERY No

EMBOLI

33915 REMOVE LUNG ARTERY No

EMBOLI

33916 SURGERY OF GREAT No

VESSEL

33917 REPAIR PULMONARY No

ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 521 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33920 REPAIR PULMONARY No

ATRESIA

33922 TRANSECT PULMONARY No

ARTERY

33924 REMOVE PULMONARY No

SHUNT

33925 RPR PUL ART UNIFOCAL No

W/O CPB

33926 REPR PUL ART UNIFOCAL No

W/CPB

33930 REMOVAL OF DONOR No

HEART/LUNG

33933 PREPARE DONOR No

HEART/LUNG

33935 TRANSPLANTATION No
HEART/LUNG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 522 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33940 REMOVAL OF DONOR No

HEART

33944 PREPARE DONOR HEART No

33945 TRANSPLANTATION OF Yes InterQual® criteria used. Provide clinical

IQ -
HEART documentation supporting rationale for
Transplant request (e.g., notes, lab values, X-rays, etc.)
Surgery

33946 ECMO/ECLS INITIATION No

VENOUS

33947 ECMO/ECLS INITIATION No

ARTERY

33948 ECMO/ECLS DAILY No

MGMT-VENOUS

33949 ECMO/ECLS DAILY MGMT No

ARTERY

33951 ECMO/ECLS INSJ PRPH No

CANNULA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 523 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33952 ECMO/ECLS INSJ PRPH No

CANNULA

33953 ECMO/ECLS INSJ PRPH No

CANNULA

33954 ECMO/ECLS INSJ PRPH No

CANNULA

33955 ECMO/ECLS INSJ CTR No

CANNULA

33956 ECMO/ECLS INSJ CTR No

CANNULA

33957 ECMO/ECLS REPOS No

PERPH CNULA

33958 ECMO/ECLS REPOS No

PERPH CNULA

33959 ECMO/ECLS REPOS No

PERPH CNULA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 524 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33962 ECMO/ECLS REPOS No

PERPH CNULA

33963 ECMO/ECLS REPOS No

PERPH CNULA

33964 ECMO/ECLS REPOS No

PERPH CNULA

33965 ECMO/ECLS RMVL PERPH No

CANNULA

33966 ECMO/ECLS RMVL PRPH No

CANNULA

33967 INSERT I-AORT PERCUT No

DEVICE

33968 REMOVE AORTIC ASSIST No

DEVICE

33969 ECMO/ECLS RMVL PERPH No

CANNULA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 525 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33970 AORTIC CIRCULATION No

ASSIST

33971 AORTIC CIRCULATION No

ASSIST

33973 INSERT BALLOON DEVICE No

33974 REMOVE INTRA-AORTIC No

BALLOON

33975 IMPLANT VENTRICULAR Yes InterQual® criteria used. Provide clinical

NH-IQ -
DEVICE documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33976 IMPLANT VENTRICULAR Yes InterQual® criteria used. Provide clinical

NH-IQ -
DEVICE documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33977 REMOVE VENTRICULAR No

DEVICE

33978 REMOVE VENTRICULAR No

DEVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 526 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33979 INSERT Yes InterQual® criteria used. Provide clinical

NH-IQ -
INTRACORPOREAL DEVICE documentation supporting rationale for
Cardiac Surg request (e.g., notes, lab values, X-rays, etc.)

33980 REMOVE No
INTRACORPOREAL DEVICE

33981 REPLACE VAD PUMP EXT No

33982 REPLACE VAD INTRA W/O No

BP

33983 REPLACE VAD INTRA No

W/BP

33984 ECMO/ECLS RMVL PRPH No

CANNULA

33985 ECMO/ECLS RMVL CTR No

CANNULA

33986 ECMO/ECLS RMVL CTR No

CANNULA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 527 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

33987 ARTERY EXPOS/GRAFT No

ARTERY

33988 INSERTION OF LEFT No

HEART VENT

33989 REMOVAL OF LEFT No

HEART VENT

33990 INSERT VAD ARTERY No

ACCESS

33991 INSERT VAD ART&VEIN No

ACCESS

33992 REMOVE VAD DIFFERENT No

SESSION

33993 REPOSITION VAD DIFF No

SESSION

33999 CARDIAC SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 528 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34001 REMOVAL OF ARTERY No

CLOT

34051 REMOVAL OF ARTERY No

CLOT

34101 REMOVAL OF ARTERY No

CLOT

34111 REMOVAL OF ARM No

ARTERY CLOT

34151 REMOVAL OF ARTERY No

CLOT

34201 REMOVAL OF ARTERY No

CLOT

34203 REMOVAL OF LEG No

ARTERY CLOT

34401 REMOVAL OF VEIN CLOT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 529 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34421 REMOVAL OF VEIN CLOT No

34451 REMOVAL OF VEIN CLOT No

34471 REMOVAL OF VEIN CLOT No

34490 REMOVAL OF VEIN CLOT No

34501 REPAIR VALVE FEMORAL No

VEIN

34502 RECONSTRUCT VENA No

CAVA

34510 TRANSPOSITION OF VEIN No

VALVE

34520 CROSS-OVER VEIN GRAFT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 530 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34530 LEG VEIN FUSION No

34800 ENDOVAS AAA REPR No

W/SM TUBE

34802 ENDOVAS AAA REPR W/2- No

P PART

34803 ENDOVAS AAA REPR W/3- No

P PART

34804 ENDOVAS AAA REPR W/1- No

P PART

34805 ENDOVAS AAA REPR No

W/LONG TUBE

34806 ANEURYSM PRESS No

SENSOR ADD-ON

34808 ENDOVAS ILIAC A DEVICE No

ADDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 531 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34812 XPOSE FOR ENDOPROSTH No

FEMORL

34813 FEMORAL ENDOVAS No

GRAFT ADD-ON

34820 XPOSE FOR ENDOPROSTH No

ILIAC

34825 ENDOVASC EXTEND No

PROSTH INIT

34826 ENDOVASC EXTEN No

PROSTH ADDL

34830 OPEN AORTIC TUBE No

PROSTH REPR

34831 OPEN AORTOILIAC No

PROSTH REPR

34832 OPEN AORTOFEMOR No

PROSTH REPR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 532 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34833 XPOSE FOR ENDOPROSTH No

ILIAC

34834 XPOSE ENDOPROSTH No

BRACHIAL

34839 PLNNING PT SPEC FENEST No

GRAFT

34841 ENDOVASC VISC AORTA 1 No

GRAFT

34842 ENDOVASC VISC AORTA 2 No

GRAFT

34843 ENDOVASC VISC AORTA 3 No

GRAFT

34844 ENDOVASC VISC AORTA 4 No

GRAFT

34845 VISC & INFRAREN ABD 1 No

PROSTH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 533 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

34846 VISC & INFRAREN ABD 2 No

PROSTH

34847 VISC & INFRAREN ABD 3 No

PROSTH

34848 VISC & INFRAREN ABD 4+ No

PROST

34900 ENDOVASC ILIAC REPR No

W/GRAFT

35001 REPAIR DEFECT OF No

ARTERY

35002 REPAIR ARTERY RUPTURE No

NECK

35005 REPAIR DEFECT OF No

ARTERY

35011 REPAIR DEFECT OF No

ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 534 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35013 REPAIR ARTERY RUPTURE No

ARM

35021 REPAIR DEFECT OF No

ARTERY

35022 REPAIR ARTERY RUPTURE No

CHEST

35045 REPAIR DEFECT OF ARM No

ARTERY

35081 REPAIR DEFECT OF No

ARTERY

35082 REPAIR ARTERY RUPTURE No

AORTA

35091 REPAIR DEFECT OF No

ARTERY

35092 REPAIR ARTERY RUPTURE No

AORTA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 535 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35102 REPAIR DEFECT OF No

ARTERY

35103 REPAIR ARTERY RUPTURE No

AORTA

35111 REPAIR DEFECT OF No

ARTERY

35112 REPAIR ARTERY RUPTURE No

SPLEEN

35121 REPAIR DEFECT OF No

ARTERY

35122 REPAIR ARTERY RUPTURE No

BELLY

35131 REPAIR DEFECT OF No

ARTERY

35132 REPAIR ARTERY RUPTURE No

GROIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 536 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35141 REPAIR DEFECT OF No

ARTERY

35142 REPAIR ARTERY RUPTURE No

THIGH

35151 REPAIR DEFECT OF No

ARTERY

35152 REPAIR RUPTD No

POPLITEAL ART

35180 REPAIR BLOOD VESSEL No

LESION

35182 REPAIR BLOOD VESSEL No

LESION

35184 REPAIR BLOOD VESSEL No

LESION

35188 REPAIR BLOOD VESSEL No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 537 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35189 REPAIR BLOOD VESSEL No

LESION

35190 REPAIR BLOOD VESSEL No

LESION

35201 REPAIR BLOOD VESSEL No

LESION

35206 REPAIR BLOOD VESSEL No

LESION

35207 REPAIR BLOOD VESSEL No

LESION

35211 REPAIR BLOOD VESSEL No

LESION

35216 REPAIR BLOOD VESSEL No

LESION

35221 REPAIR BLOOD VESSEL No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 538 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35226 REPAIR BLOOD VESSEL No

LESION

35231 REPAIR BLOOD VESSEL No

LESION

35236 REPAIR BLOOD VESSEL No

LESION

35241 REPAIR BLOOD VESSEL No

LESION

35246 REPAIR BLOOD VESSEL No

LESION

35251 REPAIR BLOOD VESSEL No

LESION

35256 REPAIR BLOOD VESSEL No

LESION

35261 REPAIR BLOOD VESSEL No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 539 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35266 REPAIR BLOOD VESSEL No

LESION

35271 REPAIR BLOOD VESSEL No

LESION

35276 REPAIR BLOOD VESSEL No

LESION

35281 REPAIR BLOOD VESSEL No

LESION

35286 REPAIR BLOOD VESSEL No

LESION

35301 RECHANNELING OF No* *PA req'd if performed as elective proc in

ARTERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

35302 RECHANNELING OF No
ARTERY

35303 RECHANNELING OF No
ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 540 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35304 RECHANNELING OF No
ARTERY

35305 RECHANNELING OF No
ARTERY

35306 RECHANNELING OF No
ARTERY

35311 RECHANNELING OF No
ARTERY

35321 RECHANNELING OF No
ARTERY

35331 RECHANNELING OF No
ARTERY

35341 RECHANNELING OF No
ARTERY

35351 RECHANNELING OF No
ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 541 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35355 RECHANNELING OF No
ARTERY

35361 RECHANNELING OF No
ARTERY

35363 RECHANNELING OF No
ARTERY

35371 RECHANNELING OF No
ARTERY

35372 RECHANNELING OF No
ARTERY

35390 REOPERATION CAROTID No

ADD-ON

35400 ANGIOSCOPY No

35450 REPAIR ARTERIAL No

BLOCKAGE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 542 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35452 REPAIR ARTERIAL No

BLOCKAGE

35458 REPAIR ARTERIAL No

BLOCKAGE

35460 REPAIR VENOUS No

BLOCKAGE

35471 REPAIR ARTERIAL No* *PA req'd if performed as elective proc in

BLOCKAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

35472 REPAIR ARTERIAL No

BLOCKAGE

35475 REPAIR ARTERIAL No* *PA req'd if performed as elective proc in

BLOCKAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

35476 REPAIR VENOUS No

BLOCKAGE

35500 HARVEST VEIN FOR No

BYPASS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 543 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35501 ART BYP GRFT IPSILAT No

CAROTID

35506 ART BYP GRFT SUBCLAV- No

CAROTID

35508 ART BYP GRFT CAROTID- No

VERTBRL

35509 ART BYP GRFT CONTRAL No

CAROTID

35510 ART BYP GRFT CAROTID- No

BRCHIAL

35511 ART BYP GRFT SUBCLAV- No

SUBCLAV

35512 ART BYP GRFT SUBCLAV- No

BRCHIAL

35515 ART BYP GRFT SUBCLAV- No

VERTBRL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 544 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35516 ART BYP GRFT SUBCLAV- No

AXILARY

35518 ART BYP GRFT AXILLARY- No

AXILRY

35521 ART BYP GRFT AXILL- No

FEMORAL

35522 ART BYP GRFT AXILL- No

BRACHIAL

35523 ART BYP GRFT BRCHL- No

ULNR-RDL

35525 ART BYP GRFT BRACHIAL- No

BRCHL

35526 ART BYP GRFT No

AOR/CAROT/INNOM

35531 ART BYP GRFT No

AORCEL/AORMESEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 545 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35533 ART BYP GRFT No

AXILL/FEM/FEM

35535 ART BYP GRFT No

HEPATORENAL

35536 ART BYP GRFT No

SPLENORENAL

35537 ART BYP GRFT No

AORTOILIAC

35538 ART BYP GRFT AORTOBI- No

ILIAC

35539 ART BYP GRFT No

AORTOFEMORAL

35540 ART BYP GRFT No

AORTBIFEMORAL

35556 ART BYP GRFT FEM- No

POPLITEAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 546 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35558 ART BYP GRFT FEM- No

FEMORAL

35560 ART BYP GRFT No

AORTORENAL

35563 ART BYP GRFT ILIOILIAC No

35565 ART BYP GRFT No

ILIOFEMORAL

35566 ART BYP FEM-ANT-POST No

TIB/PRL

35570 ART BYP TIBIAL- No

TIB/PERONEAL

35571 ART BYP POP-TIBL-PRL- No

OTHER

35572 HARVEST No
FEMOROPOPLITEAL VEIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 547 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35583 VEIN BYP GRFT FEM- No

POPLITEAL

35585 VEIN BYP FEM-TIBIAL No

PERONEAL

35587 VEIN BYP POP-TIBL No

PERONEAL

35600 HARVEST ART FOR CABG No

ADD-ON

35601 ART BYP COMMON IPSI No

CAROTID

35606 ART BYP CAROTID- No

SUBCLAVIAN

35612 ART BYP SUBCLAV- No

SUBCLAVIAN

35616 ART BYP SUBCLAV- No

AXILLARY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 548 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35621 ART BYP AXILLARY- No

FEMORAL

35623 ART BYP AXILLARY-POP- No

TIBIAL

35626 ART BYP No

AORSUBCL/CAROT/INNO
M

35631 ART BYP AOR-CELIAC- No

MSN-RENAL

35632 ART BYP ILIO-CELIAC No

35633 ART BYP ILIO- No

MESENTERIC

35634 ART BYP ILIORENAL No

35636 ART BYP SPENORENAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 549 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35637 ART BYP AORTOILIAC No

35638 ART BYP AORTOBI-ILIAC No

35642 ART BYP CAROTID- No

VERTEBRAL

35645 ART BYP SUBCLAV- No

VERTEBRL

35646 ART BYP No

AORTOBIFEMORAL

35647 ART BYP AORTOFEMORAL No

35650 ART BYP AXILLARY- No

AXILLARY

35654 ART BYP AXILL-FEM- No

FEMORAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 550 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35656 ART BYP FEMORAL- No

POPLITEAL

35661 ART BYP FEMORAL- No

FEMORAL

35663 ART BYP ILIOILIAC No

35665 ART BYP ILIOFEMORAL No

35666 ART BYP FEM-ANT-POST No

TIB/PRL

35671 ART BYP POP-TIBL-PRL- No

OTHER

35681 COMPOSITE BYP GRFT No

PROS&VEIN

35682 COMPOSITE BYP GRFT 2 No

VEINS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 551 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35683 COMPOSITE BYP GRFT No

3/> SEGMT

35685 BYPASS GRAFT No

PATENCY/PATCH

35686 BYPASS GRAFT/AV FIST No

PATENCY

35691 ART TRNSPOSJ VERTBRL No

CAROTID

35693 ART TRNSPOSJ No

SUBCLAVIAN

35694 ART TRNSPOSJ SUBCLAV No

CAROTID

35695 ART TRNSPOSJ CAROTID No

SUBCLAV

35697 REIMPLANT ARTERY EACH No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 552 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35700 REOPERATION BYPASS No

GRAFT

35701 EXPLORATION CAROTID No

ARTERY

35721 EXPLORATION FEMORAL No

ARTERY

35741 EXPLORATION POPLITEAL No

ARTERY

35761 EXPLORATION OF No
ARTERY/VEIN

35800 EXPLORE NECK VESSELS No

35820 EXPLORE CHEST VESSELS No

35840 EXPLORE ABDOMINAL No

VESSELS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 553 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35860 EXPLORE LIMB VESSELS No

35870 REPAIR VESSEL GRAFT No

DEFECT

35875 REMOVAL OF CLOT IN No

GRAFT

35876 REMOVAL OF CLOT IN No

GRAFT

35879 REVISE GRAFT W/VEIN No

35881 REVISE GRAFT W/VEIN No

35883 REVISE GRAFT No

W/NONAUTO GRAFT

35884 REVISE GRAFT W/VEIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 554 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

35901 EXCISION GRAFT NECK No

35903 EXCISION GRAFT No

EXTREMITY

35905 EXCISION GRAFT THORAX No

35907 EXCISION GRAFT No

ABDOMEN

36000 PLACE NEEDLE IN VEIN No

36002 PSEUDOANEURYSM No
INJECTION TRT

36005 INJECTION EXT No

VENOGRAPHY

36010 PLACE CATHETER IN VEIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 555 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36011 PLACE CATHETER IN VEIN No

36012 PLACE CATHETER IN VEIN No

36013 PLACE CATHETER IN No

ARTERY

36014 PLACE CATHETER IN No

ARTERY

36015 PLACE CATHETER IN No

ARTERY

36100 ESTABLISH ACCESS TO No

ARTERY

36120 ESTABLISH ACCESS TO No

ARTERY

36140 ESTABLISH ACCESS TO No

ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 556 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36147 ACCESS AV DIAL GRFT No

FOR EVAL

36148 ACCESS AV DIAL GRFT No

FOR PROC

36160 ESTABLISH ACCESS TO No

AORTA

36200 PLACE CATHETER IN No

AORTA

36215 PLACE CATHETER IN No

ARTERY

36216 PLACE CATHETER IN No

ARTERY

36217 PLACE CATHETER IN No

ARTERY

36218 PLACE CATHETER IN No

ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 557 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36221 PLACE CATH THORACIC No

AORTA

36222 PLACE CATH No

CAROTID/INOM ART

36223 PLACE CATH No

CAROTID/INOM ART

36224 PLACE CATH CAROTD ART No

36225 PLACE CATH SUBCLAVIAN No

ART

36226 PLACE CATH VERTEBRAL No

ART

36227 PLACE CATH XTRNL No

CAROTID

36228 PLACE CATH No

INTRACRANIAL ART

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 558 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36245 INS CATH ABD/L-EXT ART No

1ST

36246 INS CATH ABD/L-EXT ART No

2ND

36247 INS CATH ABD/L-EXT ART No

3RD

36248 INS CATH ABD/L-EXT ART No

ADDL

36251 INS CATH REN ART 1ST No

UNILAT

36252 INS CATH REN ART 1ST No

BILAT

36253 INS CATH REN ART 2ND+ No

UNILAT

36254 INS CATH REN ART 2ND+ No

BILAT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 559 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36260 INSERTION OF INFUSION No

PUMP

36261 REVISION OF INFUSION No

PUMP

36262 REMOVAL OF INFUSION No

PUMP

36299 VESSEL INJECTION No

PROCEDURE

36400 BL DRAW < 3 YRS No

FEM/JUGULAR

36405 BL DRAW <3 YRS SCALP No

VEIN

36406 BL DRAW <3 YRS OTHER No

VEIN

36410 NON-ROUTINE BL DRAW No

3/> YRS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 560 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36415 ROUTINE VENIPUNCTURE No

36416 CAPILLARY BLOOD DRAW No

36420 VEIN ACCESS CUTDOWN No

< 1 YR

36425 VEIN ACCESS CUTDOWN No

> 1 YR

36430 BLOOD TRANSFUSION No

SERVICE

36440 BL PUSH TRANSFUSE 2 No

YR/<

36450 BL No
EXCHANGE/TRANSFUSE
NB

36455 BL No
EXCHANGE/TRANSFUSE
NON-NB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 561 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36460 TRANSFUSION SERVICE No

FETAL

36468 INJECTION(S) SPIDER Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
VEINS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

36470 INJECTION THERAPY OF Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

36471 INJECTION THERAPY OF Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEINS *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

36475 ENDOVENOUS RF 1ST Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

36476 ENDOVENOUS RF VEIN Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ADD-ON more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

36478 ENDOVENOUS LASER 1ST Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

36479 ENDOVENOUS LASER No Cosmetic, Reconstructive, and Cosmetic, Reconstructive,

VEIN ADDON Restorative Services and Restorative Services (Eff
07/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 562 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36481 INSERTION OF CATHETER No

VEIN

36500 INSERTION OF CATHETER No

VEIN

36510 INSERTION OF CATHETER No

VEIN

36511 APHERESIS WBC No

36512 APHERESIS RBC No

36513 APHERESIS PLATELETS No

36514 APHERESIS PLASMA No

36515 APHERESIS No
ADSORP/REINFUSE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 563 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36516 APHERESIS SELECTIVE No

36522 PHOTOPHERESIS No

36555 INSERT NON-TUNNEL CV No

CATH

36556 INSERT NON-TUNNEL CV No

CATH

36557 INSERT TUNNELED CV No

CATH

36558 INSERT TUNNELED CV No

CATH

36560 INSERT TUNNELED CV No

CATH

36561 INSERT TUNNELED CV No

CATH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 564 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36563 INSERT TUNNELED CV No

CATH

36565 INSERT TUNNELED CV No

CATH

36566 INSERT TUNNELED CV No

CATH

36568 INSERT PICC CATH No

36569 INSERT PICC CATH No

36570 INSERT PICVAD CATH No

36571 INSERT PICVAD CATH No

36575 REPAIR TUNNELED CV No

CATH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 565 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36576 REPAIR TUNNELED CV No

CATH

36578 REPLACE TUNNELED CV No

CATH

36580 REPLACE CVAD CATH No

36581 REPLACE TUNNELED CV No

CATH

36582 REPLACE TUNNELED CV No

CATH

36583 REPLACE TUNNELED CV No

CATH

36584 REPLACE PICC CATH No

36585 REPLACE PICVAD CATH No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 566 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36589 REMOVAL TUNNELED CV No

CATH

36590 REMOVAL TUNNELED CV No

CATH

36591 DRAW BLOOD OFF No

VENOUS DEVICE

36592 COLLECT BLOOD FROM No

PICC

36593 DECLOT VASCULAR No

DEVICE

36595 MECH REMOV No

TUNNELED CV CATH

36596 MECH REMOV No

TUNNELED CV CATH

36597 REPOSITION VENOUS No

CATHETER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 567 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36598 INJ W/FLUOR EVAL CV No

DEVICE

36600 WITHDRAWAL OF No
ARTERIAL BLOOD

36620 INSERTION CATHETER No

ARTERY

36625 INSERTION CATHETER No

ARTERY

36640 INSERTION CATHETER No

ARTERY

36660 INSERTION CATHETER No

ARTERY

36680 INSERT NEEDLE BONE No

CAVITY

36800 INSERTION OF CANNULA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 568 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36810 INSERTION OF CANNULA No

36815 INSERTION OF CANNULA No

36818 AV FUSE UPPR ARM No

CEPHALIC

36819 AV FUSE UPPR ARM No

BASILIC

36820 AV FUSION/FOREARM No
VEIN

36821 AV FUSION DIRECT ANY No

SITE

36823 INSERTION OF No
CANNULA(S)

36825 ARTERY-VEIN AUTOGRAFT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 569 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36830 ARTERY-VEIN No
NONAUTOGRAFT

36831 OPEN THROMBECT AV No

FISTULA

36832 AV FISTULA REVISION No

OPEN

36833 AV FISTULA REVISION No

36835 ARTERY TO VEIN SHUNT No

36838 DIST REVAS LIGATION No

HEMO

36860 EXTERNAL CANNULA No

DECLOTTING

36861 CANNULA DECLOTTING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 570 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

36870 PERCUT THROMBECT AV No

FISTULA

37140 REVISION OF No
CIRCULATION

37145 REVISION OF No
CIRCULATION

37160 REVISION OF No
CIRCULATION

37180 REVISION OF No
CIRCULATION

37181 SPLICE SPLEEN/KIDNEY No

VEINS

37182 INSERT HEPATIC SHUNT No

(TIPS)

37183 REMOVE HEPATIC SHUNT No

(TIPS)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 571 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37184 PRIM ART M-THRMBC No

1ST VSL

37185 PRIM ART M-THRMBC No

SBSQ VSL

37186 SEC ART No

THROMBECTOMY ADD-
ON

37187 VENOUS MECH No

THROMBECTOMY

37188 VENOUS M- No
THROMBECTOMY ADD-
ON

37191 INS ENDOVAS VENA No

CAVA FILTR

37192 REDO ENDOVAS VENA No

CAVA FILTR

37193 REM ENDOVAS VENA No

CAVA FILTER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 572 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37195 THROMBOLYTIC No
THERAPY STROKE

37197 REMOVE INTRVAS No

FOREIGN BODY

37200 TRANSCATHETER BIOPSY No

37211 THROMBOLYTIC ART No

THERAPY

37212 THROMBOLYTIC VENOUS No

THERAPY

37213 THROMBLYTIC ART/VEN No

THERAPY

37214 CESSJ THERAPY CATH No

REMOVAL

37215 TRANSCATH STENT CCA No* *PA req'd if performed as elective proc in
W/EPS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 573 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37216 TRANSCATH STENT CCA No* *PA req'd if performed as elective proc in
W/O EPS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

37217 STENT PLACEMT RETRO No

CAROTID

37218 STENT PLACEMT ANTE No

CAROTID

37220 ILIAC REVASC Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
more details
Experimental/I
nvestigation

37221 ILIAC REVASC W/STENT Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
more details
Experimental/I
nvestigation

37222 ILIAC REVASC ADD-ON No

37223 ILIAC REVASC W/STENT Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ADD-ON more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

37224 FEM/POPL REVAS W/TLA Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
more details
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 574 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37225 FEM/POPL REVAS Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
W/ATHER more details
Experimental/I
nvestigation

37226 FEM/POPL REVASC Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
W/STENT more details
Experimental/I
nvestigation

37227 FEM/POPL REVASC STNT Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
& ATHER more details
Experimental/I
nvestigation

37228 TIB/PER REVASC W/TLA Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
more details
Experimental/I
nvestigation

37229 TIB/PER REVASC Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
W/ATHER more details
Experimental/I
nvestigation

37230 TIB/PER REVASC W/STENT Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
more details
Experimental/I
nvestigation

37231 TIB/PER REVASC STENT & Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
ATHER more details
Experimental/I
nvestigation

37232 TIB/PER REVASC ADD-ON Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 575 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37233 TIBPER REVASC W/ATHER Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ADD-ON more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

37234 REVSC OPN/PRQ Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
TIB/PERO STENT more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

37235 TIB/PER REVASC STNT & Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ATHER more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

37236 OPEN/PERQ PLACE STENT No

1ST

37237 OPEN/PERQ PLACE STENT No

EA ADD

37238 OPEN/PERQ PLACE STENT No

SAME

37239 OPEN/PERQ PLACE STENT No

EA ADD

37241 VASC No
EMBOLIZE/OCCLUDE
VENOUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 576 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37242 VASC No
EMBOLIZE/OCCLUDE
ARTERY

37243 VASC No
EMBOLIZE/OCCLUDE
ORGAN

37244 VASC No
EMBOLIZE/OCCLUDE
BLEED

37252 INTRVASC US No
NONCORONARY 1ST

37253 INTRVASC US No
NONCORONARY ADDL

37500 ENDOSCOPY LIGATE PERF Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-IQ -
VEINS more details
Varicose Vein
Surgery

37501 VASCULAR ENDOSCOPY No

PROCEDURE

37565 LIGATION OF NECK VEIN No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 577 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37600 LIGATION OF NECK No

ARTERY

37605 LIGATION OF NECK No

ARTERY

37606 LIGATION OF NECK No

ARTERY

37607 LIGATION OF A-V FISTULA No

37609 TEMPORAL ARTERY No

PROCEDURE

37615 LIGATION OF NECK No

ARTERY

37616 LIGATION OF CHEST No

ARTERY

37617 LIGATION OF ABDOMEN No

ARTERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 578 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37618 LIGATION OF EXTREMITY No

ARTERY

37619 LIGATION OF INF VENA No

CAVA

37650 REVISION OF MAJOR VEIN No

37660 REVISION OF MAJOR VEIN No

37700 REVISE LEG VEIN Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

37718 LIGATE/STRIP SHORT LEG Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

37722 LIGATE/STRIP LONG LEG Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

37735 REMOVAL OF LEG Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
NH-IQ -
VEINS/LESION more details Restorative Services and Restorative Services (Eff
Varicose Vein 07/01/18)
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 579 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37760 LIGATE LEG VEINS Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
RADICAL *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

37761 LIGATE LEG VEINS OPEN Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

37765 STAB PHLEB VEINS XTR Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
10-20 *Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

37766 PHLEB VEINS - EXTREM Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
20+ *Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

37780 REVISION OF LEG VEIN Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

37785 LIGATE/DIVIDE/EXCISE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
VEIN *Will be covered only when performed in
Varicose Vein the Outpatient setting.
Surgery

37788 REVASCULARIZATION Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PENIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

37790 PENILE VENOUS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
OCCLUSION more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 580 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

37799 VASCULAR SURGERY Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
PROCEDURE *Will be covered only when performed in
Potentially the Outpatient setting.
cosmetic

digestive system
40490 BIOPSY OF LIP No

40500 PARTIAL EXCISION OF LIP No

40510 PARTIAL EXCISION OF LIP No

40520 PARTIAL EXCISION OF LIP No

40525 RECONSTRUCT LIP WITH No

FLAP

40527 RECONSTRUCT LIP WITH No

FLAP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 581 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

40530 PARTIAL REMOVAL OF LIP No

40650 REPAIR LIP No

40652 REPAIR LIP No

40654 REPAIR LIP No

40700 REPAIR CLEFT LIP/NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

40701 REPAIR CLEFT LIP/NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

40702 REPAIR CLEFT LIP/NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

40720 REPAIR CLEFT LIP/NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 582 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

40761 REPAIR CLEFT LIP/NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

40799 LIP SURGERY PROCEDURE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

40800 DRAINAGE OF MOUTH No

LESION

40801 DRAINAGE OF MOUTH No

LESION

40804 REMOVAL FOREIGN No

BODY MOUTH

40805 REMOVAL FOREIGN No

BODY MOUTH

40806 INCISION OF LIP FOLD No

40808 BIOPSY OF MOUTH No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 583 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

40810 EXCISION OF MOUTH No

LESION

40812 EXCISE/REPAIR MOUTH No

LESION

40814 EXCISE/REPAIR MOUTH No

LESION

40816 EXCISION OF MOUTH No

LESION

40818 EXCISE ORAL MUCOSA No

FOR GRAFT

40819 EXCISE LIP OR CHEEK No

FOLD

40820 TREATMENT OF MOUTH No

LESION

40830 REPAIR MOUTH No

LACERATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 584 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

40831 REPAIR MOUTH No

LACERATION

40840 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Oral
MOUTH rationale for request (e.g., notes, lab
Maxillofacial values, X-rays, etc.)
Surgery

40842 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Oral
MOUTH rationale for request (e.g., notes, lab
Maxillofacial values, X-rays, etc.)
Surgery

40843 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Oral
MOUTH rationale for request (e.g., notes, lab
Maxillofacial values, X-rays, etc.)
Surgery

40844 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Oral
MOUTH rationale for request (e.g., notes, lab
Maxillofacial values, X-rays, etc.)
Surgery

40845 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Oral
MOUTH rationale for request (e.g., notes, lab
Maxillofacial values, X-rays, etc.)
Surgery

40899 MOUTH SURGERY No

PROCEDURE

41000 DRAINAGE OF MOUTH No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 585 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41005 DRAINAGE OF MOUTH No

LESION

41006 DRAINAGE OF MOUTH No

LESION

41007 DRAINAGE OF MOUTH No

LESION

41008 DRAINAGE OF MOUTH No

LESION

41009 DRAINAGE OF MOUTH No

LESION

41010 INCISION OF TONGUE No

FOLD

41015 DRAINAGE OF MOUTH No

LESION

41016 DRAINAGE OF MOUTH No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 586 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41017 DRAINAGE OF MOUTH No

LESION

41018 DRAINAGE OF MOUTH No

LESION

41019 PLACE NEEDLES H&N FOR No

RT

41100 BIOPSY OF TONGUE No

41105 BIOPSY OF TONGUE No

41108 BIOPSY OF FLOOR OF No

MOUTH

41110 EXCISION OF TONGUE No

LESION

41112 EXCISION OF TONGUE No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 587 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41113 EXCISION OF TONGUE No

LESION

41114 EXCISION OF TONGUE No

LESION

41115 EXCISION OF TONGUE No

FOLD

41116 EXCISION OF MOUTH No

LESION

41120 PARTIAL REMOVAL OF No

TONGUE

41130 PARTIAL REMOVAL OF No

TONGUE

41135 TONGUE AND NECK No

SURGERY

41140 REMOVAL OF TONGUE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 588 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41145 TONGUE REMOVAL NECK No

SURGERY

41150 TONGUE MOUTH JAW No

SURGERY

41153 TONGUE MOUTH NECK No

SURGERY

41155 TONGUE JAW & NECK No

SURGERY

41250 REPAIR TONGUE No

LACERATION

41251 REPAIR TONGUE No

LACERATION

41252 REPAIR TONGUE No

LACERATION

41500 FIXATION OF TONGUE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 589 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41510 TONGUE TO LIP SURGERY No

41512 TONGUE SUSPENSION Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

41520 RECONSTRUCTION No
TONGUE FOLD

41530 TONGUE BASE VOL Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
REDUCTION more details Treatment Investigational Treatmen
Experimental/I
nvestigation

41599 TONGUE AND MOUTH No

SURGERY

41800 DRAINAGE OF GUM No

LESION

41805 REMOVAL FOREIGN No

BODY GUM

41806 REMOVAL FOREIGN No

BODY JAWBONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 590 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41820 EXCISION GUM EACH No

QUADRANT

41821 EXCISION OF GUM FLAP No

41822 EXCISION OF GUM LESION No

41823 EXCISION OF GUM LESION No

41825 EXCISION OF GUM LESION No

41826 EXCISION OF GUM LESION No

41827 EXCISION OF GUM LESION No

41828 EXCISION OF GUM LESION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 591 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

41830 REMOVAL OF GUM No

TISSUE

41850 TREATMENT OF GUM No

LESION

41870 GUM GRAFT No

41872 REPAIR GUM No

41874 REPAIR TOOTH SOCKET No

41899 DENTAL SURGERY No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

42000 DRAINAGE MOUTH ROOF No

LESION

42100 BIOPSY ROOF OF MOUTH No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 592 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42104 EXCISION LESION MOUTH No

ROOF

42106 EXCISION LESION MOUTH No

ROOF

42107 EXCISION LESION MOUTH No

ROOF

42120 REMOVE PALATE/LESION Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42140 EXCISION OF UVULA Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42145 REPAIR PALATE Yes* Please review BMCHP criteria for details. Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
NH-IQ - ENT
PHARYNX/UVULA *Will be covered only when performed in Restorative Services and Restorative Services (Eff
Surg the Outpatient setting. 07/01/18)

42160 TREATMENT MOUTH Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ROOF LESION more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42180 REPAIR PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 593 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42182 REPAIR PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42200 RECONSTRUCT CLEFT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PALATE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42205 RECONSTRUCT CLEFT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PALATE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42210 RECONSTRUCT CLEFT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PALATE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42215 RECONSTRUCT CLEFT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PALATE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42220 RECONSTRUCT CLEFT No

PALATE

42225 RECONSTRUCT CLEFT No

PALATE

42226 LENGTHENING OF PALATE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 594 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42227 LENGTHENING OF PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42235 REPAIR PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42260 REPAIR NOSE TO LIP Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
FISTULA more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42280 PREPARATION PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
MOLD more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42281 INSERTION PALATE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42299 PALATE/UVULA SURGERY Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42300 DRAINAGE OF SALIVARY Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
GLAND more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

42305 DRAINAGE OF SALIVARY Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
GLAND more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 595 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42310 DRAINAGE OF SALIVARY No

GLAND

42320 DRAINAGE OF SALIVARY No

GLAND

42330 REMOVAL OF SALIVARY No

STONE

42335 REMOVAL OF SALIVARY No

STONE

42340 REMOVAL OF SALIVARY No

STONE

42400 BIOPSY OF SALIVARY No

GLAND

42405 BIOPSY OF SALIVARY No

GLAND

42408 EXCISION OF SALIVARY No

CYST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 596 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42409 DRAINAGE OF SALIVARY No

CYST

42410 EXCISE PAROTID No

GLAND/LESION

42415 EXCISE PAROTID No

GLAND/LESION

42420 EXCISE PAROTID No

GLAND/LESION

42425 EXCISE PAROTID No

GLAND/LESION

42426 EXCISE PAROTID No

GLAND/LESION

42440 EXCISE SUBMAXILLARY No

GLAND

42450 EXCISE SUBLINGUAL No

GLAND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 597 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42500 REPAIR SALIVARY DUCT No

42505 REPAIR SALIVARY DUCT No

42507 PAROTID DUCT No

DIVERSION

42509 PAROTID DUCT No

DIVERSION

42510 PAROTID DUCT No

DIVERSION

42550 INJECTION FOR SALIVARY No

X-RAY

42600 CLOSURE OF SALIVARY No

FISTULA

42650 DILATION OF SALIVARY No

DUCT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 598 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42660 DILATION OF SALIVARY No

DUCT

42665 LIGATION OF SALIVARY No

DUCT

42699 SALIVARY SURGERY No

PROCEDURE

42700 DRAINAGE OF TONSIL No

ABSCESS

42720 DRAINAGE OF THROAT No

ABSCESS

42725 DRAINAGE OF THROAT No

ABSCESS

42800 BIOPSY OF THROAT No

42804 BIOPSY OF UPPER No

NOSE/THROAT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 599 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42806 BIOPSY OF UPPER No

NOSE/THROAT

42808 EXCISE PHARYNX LESION No

42809 REMOVE PHARYNX No

FOREIGN BODY

42810 EXCISION OF NECK CYST No

42815 EXCISION OF NECK CYST No

42820 REMOVE TONSILS AND No

ADENOIDS

42821 REMOVE TONSILS AND No* *PA req'd if performed as elective proc in
ADENOIDS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

42825 REMOVAL OF TONSILS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 600 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42826 REMOVAL OF TONSILS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

42830 REMOVAL OF ADENOIDS No

42831 REMOVAL OF ADENOIDS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

42835 REMOVAL OF ADENOIDS No

42836 REMOVAL OF ADENOIDS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

42842 EXTENSIVE SURGERY OF No

THROAT

42844 EXTENSIVE SURGERY OF No

THROAT

42845 EXTENSIVE SURGERY OF No

THROAT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 601 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42860 EXCISION OF TONSIL TAGS No

42870 EXCISION OF LINGUAL No

TONSIL

42890 PARTIAL REMOVAL OF No

PHARYNX

42892 REVISION OF No
PHARYNGEAL WALLS

42894 REVISION OF No
PHARYNGEAL WALLS

42900 REPAIR THROAT WOUND No

42950 RECONSTRUCTION OF No
THROAT

42953 REPAIR THROAT No

ESOPHAGUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 602 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

42955 SURGICAL OPENING OF No

THROAT

42960 CONTROL THROAT No

BLEEDING

42961 CONTROL THROAT No

BLEEDING

42962 CONTROL THROAT No

BLEEDING

42970 CONTROL NOSE/THROAT No

BLEEDING

42971 CONTROL NOSE/THROAT No

BLEEDING

42972 CONTROL NOSE/THROAT No

BLEEDING

42999 THROAT SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 603 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43020 INCISION OF ESOPHAGUS No

43030 THROAT MUSCLE No

SURGERY

43045 INCISION OF ESOPHAGUS No

43100 EXCISION OF ESOPHAGUS No

LESION

43101 EXCISION OF ESOPHAGUS No

LESION

43107 REMOVAL OF No
ESOPHAGUS

43108 REMOVAL OF No
ESOPHAGUS

43112 REMOVAL OF No
ESOPHAGUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 604 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43113 REMOVAL OF No
ESOPHAGUS

43116 PARTIAL REMOVAL OF No

ESOPHAGUS

43117 PARTIAL REMOVAL OF No

ESOPHAGUS

43118 PARTIAL REMOVAL OF No

ESOPHAGUS

43121 PARTIAL REMOVAL OF No

ESOPHAGUS

43122 PARTIAL REMOVAL OF No

ESOPHAGUS

43123 PARTIAL REMOVAL OF No

ESOPHAGUS

43124 REMOVAL OF No
ESOPHAGUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 605 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43130 REMOVAL OF No
ESOPHAGUS POUCH

43135 REMOVAL OF No
ESOPHAGUS POUCH

43180 ESOPHAGOSCOPY RIGID No

TRNSO

43191 ESOPHAGOSCOPY RIGID No

TRNSO DX

43192 ESOPHAGOSCP RIG Yes Please review the Well Sense Policy for Endoscopic Treatments for GERD in Endoscopic Treatments for
NH-
TRNSO INJECT more details the Outpatient Setting GERD in the Outpatient
endoscopic Setting ( Eff 12/01/18)
Surg for GERD
OP

43193 ESOPHAGOSCP RIG No

TRNSO BIOPSY

43194 ESOPHAGOSCP RIG No

TRNSO REM FB

43195 ESOPHAGOSCOPY RIGID No

BALLOON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 606 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43196 ESOPHAGOSCP GUIDE No

WIRE DILAT

43197 ESOPHAGOSCOPY FLEX No

DX BRUSH

43198 ESOPHAGOSC FLEX No

TRNSN BIOPSY

43200 ESOPHAGOSCOPY No* *PA req'd if performed as elective proc in

FLEXIBLE BRUSH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43201 ESOPH SCOPE Yes* Please review BMCHP criteria for details. Endoscopic Treatments for GERD in Endoscopic Treatments for
NH-
W/SUBMUCOUS INJ *Will be covered only when performed in the Outpatient Setting GERD in the Outpatient
endoscopic the Outpatient setting. Setting ( Eff 12/01/18)
Surg for GERD
OP

43202 ESOPHAGOSCOPY FLEX No* *PA req'd if performed as elective proc in

BIOPSY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43204 ESOPH SCOPE No

W/SCLEROSIS INJ

43205 ESOPHAGUS No* *PA req'd if performed as elective proc in

ENDOSCOPY/LIGATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 607 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43206 ESOPH OPTICAL No* *PA req'd if performed as elective proc in

ENDOMICROSCOPY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43210 EGD ESOPHAGOGASTRC Yes Please review the Well Sense Policy for Endoscopic Treatments for GERD in Endoscopic Treatments for
FNDOPLSTY more details the Outpatient Setting GERD in the Outpatient
Setting ( Eff 12/01/18)

43211 ESOPHAGOSCOP No
MUCOSAL RESECT

43212 ESOPHAGOSCOP STENT Yes Please review the Well Sense Policy for Endoscopic Treatments for GERD in Endoscopic Treatments for
PLACEMENT more details the Outpatient Setting GERD in the Outpatient
Setting ( Eff 12/01/18)

43213 ESOPHAGOSCOPY RETRO No

BALLOON

43214 ESOPHAGOSC DILATE No

BALLOON 30

43215 ESOPHAGOSCOPY FLEX No* *PA req'd if performed as elective proc in

REMOVE FB the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43216 ESOPHAGOSCOPY LESION No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 608 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43217 ESOPHAGOSCOPY SNARE No* *PA req'd if performed as elective proc in

LES REMV the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43220 ESOPHAGOSCOPY No* *PA req'd if performed as elective proc in

BALLOON <30MM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43226 ESOPH ENDOSCOPY No* *PA req'd if performed as elective proc in

DILATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43227 ESOPHAGOSCOPY No* *PA req'd if performed as elective proc in

CONTROL BLEED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43229 ESOPHAGOSCOPY LESION No

ABLATE

43231 ESOPHAGOSCOP No* *PA req'd if performed as elective proc in

ULTRASOUND EXAM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43232 ESOPHAGOSCOPY W/US No* *PA req'd if performed as elective proc in

NEEDLE BX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43233 EGD BALLOON DIL No

ESOPH30 MM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 609 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43235 EGD DIAGNOSTIC BRUSH No* *PA req'd if performed as elective proc in
WASH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43236 UPPR GI SCOPE Yes* Please review BMCHP criteria for details. Endoscopic Treatments for GERD in Endoscopic Treatments for
NH-
W/SUBMUC INJ *Will be covered only when performed in the Outpatient Setting GERD in the Outpatient
endoscopic the Outpatient setting. Setting ( Eff 12/01/18)
Surg for GERD
OP

43237 ENDOSCOPIC US EXAM No* *PA req'd if performed as elective proc in

ESOPH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43238 EGD US FINE NEEDLE No* *PA req'd if performed as elective proc in
BX/ASPIR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43239 EGD BIOPSY No* *PA req'd if performed as elective proc in

SINGLE/MULTIPLE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43240 EGD W/TRANSMURAL No* *PA req'd if performed as elective proc in

DRAIN CYST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43241 EGD TUBE/CATH No* *PA req'd if performed as elective proc in

INSERTION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43242 EGD US FINE NEEDLE No* *PA req'd if performed as elective proc in
BX/ASPIR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 610 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43243 EGD INJECTION VARICES No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43244 EGD VARICES LIGATION No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43245 EGD DILATE STRICTURE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43246 EGD PLACE No* *PA req'd if performed as elective proc in

GASTROSTOMY TUBE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43247 EGD REMOVE FOREIGN No* *PA req'd if performed as elective proc in
BODY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43248 EGD GUIDE WIRE No* *PA req'd if performed as elective proc in
INSERTION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43249 ESOPH EGD DILATION No* *PA req'd if performed as elective proc in
<30 MM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43250 EGD CAUTERY TUMOR No* *PA req'd if performed as elective proc in
POLYP the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 611 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43251 EGD REMOVE LESION No* *PA req'd if performed as elective proc in
SNARE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43252 EGD OPTICAL No* *PA req'd if performed as elective proc in

ENDOMICROSCOPY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43253 EGD US TRANSMURAL No

INJXN/MARK

43254 EGD ENDO MUCOSAL Yes Please review the Well Sense Policy for Endoscopic Treatments for GERD in Endoscopic Treatments for
RESECTION more details the Outpatient Setting GERD in the Outpatient
Setting ( Eff 12/01/18)

43255 EGD CONTROL BLEEDING No* *PA req'd if performed as elective proc in
ANY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43257 EGD W/THRML TXMNT Yes* Please review BMCHP criteria for details. Endoscopic Treatments for GERD in Endoscopic Treatments for
NH-
GERD *Will be covered only when performed in the Outpatient Setting GERD in the Outpatient
endoscopic the Outpatient setting. Setting ( Eff 12/01/18)
Surg for GERD
OP

43259 EGD US EXAM No* *PA req'd if performed as elective proc in

DUODENUM/JEJUNUM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

43260 ERCP W/SPECIMEN No

COLLECTION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 612 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43261 ENDO No
CHOLANGIOPANCREATOG
RAPH

43262 ENDO No
CHOLANGIOPANCREATOG
RAPH

43263 ERCP SPHINCTER No

PRESSURE MEAS

43264 ERCP REMOVE DUCT No

CALCULI

43265 ERCP LITHOTRIPSY No

CALCULI

43266 EGD ENDOSCOPIC STENT No

PLACE

43270 EGD LESION ABLATION No

43273 ENDOSCOPIC No
PANCREATOSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 613 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43274 ERCP DUCT STENT No

PLACEMENT

43275 ERCP REMOVE FORGN No

BODY DUCT

43276 ERCP STENT EXCHANGE No

W/DILATE

43277 ERCP EA DUCT/AMPULLA No

DILATE

43278 ERCP LESION ABLATE No

W/DILATE

43279 LAP MYOTOMY HELLER No

43280 LAPAROSCOPY No
FUNDOPLASTY

43281 LAP PARAESOPHAG HERN No

REPAIR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 614 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43282 LAP PARAESOPH HER RPR No

W/MESH

43283 LAP ESOPH LENGTHENING No

43289 LAPAROSCOPE PROC No

ESOPH

43300 REPAIR OF ESOPHAGUS No

43305 REPAIR ESOPHAGUS AND No

FISTULA

43310 REPAIR OF ESOPHAGUS No

43312 REPAIR ESOPHAGUS AND No

FISTULA

43313 ESOPHAGOPLASTY No
CONGENITAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 615 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43314 TRACHEO- No
ESOPHAGOPLASTY CONG

43320 FUSE ESOPHAGUS & No

STOMACH

43325 REVISE ESOPHAGUS & No

STOMACH

43327 ESOPH FUNDOPLASTY LAP No InterQual® criteria is available

43328 ESOPH FUNDOPLASTY No InterQual® criteria is available

THOR

43330 ESOPHAGOMYOTOMY No
ABDOMINAL

43331 ESOPHAGOMYOTOMY No
THORACIC

43332 TRANSAB ESOPH HIAT No InterQual® criteria is available

HERN RPR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 616 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43333 TRANSAB ESOPH HIAT No InterQual® criteria is available

HERN RPR

43334 TRANSTHOR DIAPHRAG No InterQual® criteria is available

HERN RPR

43335 TRANSTHOR DIAPHRAG No InterQual® criteria is available

HERN RPR

43336 THORABD DIAPHR HERN No InterQual® criteria is available

REPAIR

43337 THORABD DIAPHR HERN No InterQual® criteria is available

REPAIR

43338 ESOPH LENGTHENING No

43340 FUSE ESOPHAGUS & No

INTESTINE

43341 FUSE ESOPHAGUS & No

INTESTINE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 617 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43351 SURGICAL OPENING No

ESOPHAGUS

43352 SURGICAL OPENING No

ESOPHAGUS

43360 GASTROINTESTINAL No
REPAIR

43361 GASTROINTESTINAL No
REPAIR

43400 LIGATE ESOPHAGUS No

VEINS

43401 ESOPHAGUS SURGERY No

FOR VEINS

43405 LIGATE/STAPLE No
ESOPHAGUS

43410 REPAIR ESOPHAGUS No

WOUND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 618 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43415 REPAIR ESOPHAGUS No

WOUND

43420 REPAIR ESOPHAGUS No

OPENING

43425 REPAIR ESOPHAGUS No

OPENING

43450 DILATE ESOPHAGUS No

1/MULT PASS

43453 DILATE ESOPHAGUS No

43460 PRESSURE TREATMENT No

ESOPHAGUS

43496 FREE JEJUNUM FLAP No

MICROVASC

43499 ESOPHAGUS SURGERY Yes* InterQual® criteria used. *Will be covered

IQ - GI Surgery
PROCEDURE only when performed in the Outpatient
setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 619 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43500 SURGICAL OPENING OF No

STOMACH

43501 SURGICAL REPAIR OF No

STOMACH

43502 SURGICAL REPAIR OF No

STOMACH

43510 SURGICAL OPENING OF No

STOMACH

43520 INCISION OF PYLORIC No

MUSCLE

43605 BIOPSY OF STOMACH No

43610 EXCISION OF STOMACH No

LESION

43611 EXCISION OF STOMACH No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 620 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43620 REMOVAL OF STOMACH No

43621 REMOVAL OF STOMACH No

43622 REMOVAL OF STOMACH No

43631 REMOVAL OF STOMACH No

PARTIAL

43632 REMOVAL OF STOMACH No

PARTIAL

43633 REMOVAL OF STOMACH No

PARTIAL

43634 REMOVAL OF STOMACH No

PARTIAL

43635 REMOVAL OF STOMACH No

PARTIAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 621 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43640 VAGOTOMY & PYLORUS Yes Provide clinical documentation supporting

IQ - GI Surgery
REPAIR rationale for request (e.g., notes, lab
values, X-rays, etc.)

43641 VAGOTOMY & PYLORUS Yes Provide clinical documentation supporting

IQ - GI Surgery
REPAIR rationale for request (e.g., notes, lab
values, X-rays, etc.)

43644 LAP GASTRIC Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
BYPASS/ROUX-EN-Y more details 002/01/18)
Surgery

43645 LAP GASTR BYPASS INCL Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
SMLL I more details 002/01/18)
Surgery

43647 LAP IMPL ELECTRODE Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ - GI Surgery
ANTRUM more details

43648 LAP REVISE/REMV ELTRD Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ - GI Surgery
ANTRUM more details

43651 LAPAROSCOPY VAGUS No

NERVE

43652 LAPAROSCOPY VAGUS No

NERVE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 622 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43653 LAPAROSCOPY No
GASTROSTOMY

43659 LAPAROSCOPE PROC Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
STOM more details 002/01/18)
Surgery

43752 NASAL/OROGASTRIC No
W/TUBE PLMT

43753 TX GASTRO INTUB W/ASP No

43754 DX GASTR INTUB W/ASP No

SPEC

43755 DX GASTR INTUB W/ASP No

SPECS

43756 DX DUOD INTUB W/ASP No

SPEC

43757 DX DUOD INTUB W/ASP No

SPECS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 623 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43760 CHANGE GASTROSTOMY No

TUBE

43761 REPOSITION No
GASTROSTOMY TUBE

43770 LAP PLACE GASTR ADJ Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
DEVICE more details 002/01/18)
Surgery

43771 LAP REVISE GASTR ADJ Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
DEVICE more details 002/01/18)
Surgery

43772 LAP RMVL GASTR ADJ Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
DEVICE more details 002/01/18)
Surgery

43773 LAP REPLACE GASTR ADJ Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
DEVICE more details 002/01/18)
Surgery

43774 LAP RMVL GASTR ADJ ALL Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
PARTS more details 002/01/18)
Surgery

43775 LAP SLEEVE Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
GASTRECTOMY more details 002/01/18)
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 624 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43800 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - GI Surgery
PYLORUS rationale for request (e.g., notes, lab
values, X-rays, etc.)

43810 FUSION OF STOMACH No

AND BOWEL

43820 FUSION OF STOMACH No

AND BOWEL

43825 FUSION OF STOMACH No

AND BOWEL

43830 PLACE GASTROSTOMY No

TUBE

43831 PLACE GASTROSTOMY No

TUBE

43832 PLACE GASTROSTOMY No

TUBE

43840 REPAIR OF STOMACH No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 625 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43842 V-BAND GASTROPLASTY Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
more details 002/01/18)
Surgery

43843 GASTROPLASTY W/O V- Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
BAND more details 002/01/18)
Surgery

43845 GASTROPLASTY Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
DUODENAL SWITCH more details 002/01/18)
Surgery

43846 GASTRIC BYPASS FOR Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
OBESITY more details 002/01/18)
Surgery

43847 GASTRIC BYPASS INCL Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
SMALL I more details 002/01/18)
Surgery

43848 REVISION GASTROPLASTY Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
more details 002/01/18)
Surgery

43850 REVISE STOMACH- No

BOWEL FUSION

43855 REVISE STOMACH- No

BOWEL FUSION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 626 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43860 REVISE STOMACH- No

BOWEL FUSION

43865 REVISE STOMACH- No

BOWEL FUSION

43870 REPAIR STOMACH No

OPENING

43880 REPAIR STOMACH- No

BOWEL FISTULA

43881 IMPL/REDO ELECTRD Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ - GI Surgery
ANTRUM more details

43882 REVISE/REMOVE Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ - GI Surgery
ELECTRD ANTRUM more details

43886 REVISE GASTRIC PORT Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
OPEN more details 002/01/18)
Surgery

43887 REMOVE GASTRIC PORT Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
OPEN more details 002/01/18)
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 627 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

43888 CHANGE GASTRIC PORT Yes Please review the Well Sense Policy for Bariatric Surgery Bariatric Surgery (Eff
IQ-Bariatric
OPEN more details 002/01/18)
Surgery

43999 STOMACH SURGERY No

PROCEDURE

44005 FREEING OF BOWEL No

ADHESION

44010 INCISION OF SMALL No

BOWEL

44015 INSERT NEEDLE CATH No

BOWEL

44020 EXPLORE SMALL No

INTESTINE

44021 DECOMPRESS SMALL No

BOWEL

44025 INCISION OF LARGE No

BOWEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 628 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44050 REDUCE BOWEL No

OBSTRUCTION

44055 CORRECT MALROTATION No

OF BOWEL

44100 BIOPSY OF BOWEL No

44110 EXCISE INTESTINE No* *PA req'd if performed as elective proc in

LESION(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

44111 EXCISION OF BOWEL No* *PA req'd if performed as elective proc in

LESION(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

44120 REMOVAL OF SMALL No

INTESTINE

44121 REMOVAL OF SMALL No

INTESTINE

44125 REMOVAL OF SMALL No

INTESTINE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 629 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44126 ENTERECTOMY W/O No

TAPER CONG

44127 ENTERECTOMY W/TAPER No

CONG

44128 ENTERECTOMY CONG No

ADD-ON

44130 BOWEL TO BOWEL No

FUSION

44132 ENTERECTOMY CADAVER No

DONOR

44133 ENTERECTOMY LIVE Yes Please review the Well Sense Policy for Transplantation of Small Bowel, Transplantation of Small
NH-Transplant
DONOR more details Small Bowel-Liver, or Mulitivisceral Bowel, Small Bowel-Liver, or
Small Bowel Organs Mulitivisceral Organs (Eff
04/01/18)

44135 INTESTINE TRANSPLNT Yes Please review the Well Sense Policy for Transplantation of Small Bowel, Transplantation of Small
NH-Transplant
CADAVER more details Small Bowel-Liver, or Mulitivisceral Bowel, Small Bowel-Liver, or
Small Bowel Organs Mulitivisceral Organs (Eff
04/01/18)

44136 INTESTINE TRANSPLANT Yes Please review the Well Sense Policy for Transplantation of Small Bowel, Transplantation of Small
NH-Transplant
LIVE more details Small Bowel-Liver, or Mulitivisceral Bowel, Small Bowel-Liver, or
Small Bowel Organs Mulitivisceral Organs (Eff
04/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 630 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44137 REMOVE INTESTINAL No

ALLOGRAFT

44139 MOBILIZATION OF COLON No

44140 PARTIAL REMOVAL OF No

COLON

44141 PARTIAL REMOVAL OF No

COLON

44143 PARTIAL REMOVAL OF No

COLON

44144 PARTIAL REMOVAL OF No

COLON

44145 PARTIAL REMOVAL OF No

COLON

44146 PARTIAL REMOVAL OF No

COLON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 631 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44147 PARTIAL REMOVAL OF No

COLON

44150 REMOVAL OF COLON No

44151 REMOVAL OF No
COLON/ILEOSTOMY

44155 REMOVAL OF No
COLON/ILEOSTOMY

44156 REMOVAL OF No
COLON/ILEOSTOMY

44157 COLECTOMY No
W/ILEOANAL ANAST

44158 COLECTOMY W/NEO- No

RECTUM POUCH

44160 REMOVAL OF COLON No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 632 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44180 LAP ENTEROLYSIS No

44186 LAP JEJUNOSTOMY No

44187 LAP ILEO/JEJUNO-STOMY No

44188 LAP COLOSTOMY No

44202 LAP ENTERECTOMY No

44203 LAP RESECT S/INTESTINE No

ADDL

44204 LAPARO PARTIAL No

COLECTOMY

44205 LAP COLECTOMY PART No

W/ILEUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 633 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44206 LAP PART COLECTOMY No

W/STOMA

44207 L No
COLECTOMY/COLOPROCT
OSTOMY

44208 L No
COLECTOMY/COLOPROCT
OSTOMY

44210 LAPARO TOTAL No

PROCTOCOLECTOMY

44211 LAP COLECTOMY No

W/PROCTECTOMY

44212 LAPARO TOTAL No

PROCTOCOLECTOMY

44213 LAP MOBIL SPLENIC FL No

ADD-ON

44227 LAP CLOSE No

ENTEROSTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 634 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44238 LAPAROSCOPE PROC No

INTESTINE

44300 OPEN BOWEL TO SKIN No

44310 ILEOSTOMY/JEJUNOSTOM No
Y

44312 REVISION OF ILEOSTOMY No

44314 REVISION OF ILEOSTOMY No

44316 DEVISE BOWEL POUCH No

44320 COLOSTOMY No

44322 COLOSTOMY WITH No

BIOPSIES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 635 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44340 REVISION OF COLOSTOMY No

44345 REVISION OF COLOSTOMY No

44346 REVISION OF COLOSTOMY No

44360 SMALL BOWEL No

ENDOSCOPY

44361 SMALL BOWEL No

ENDOSCOPY/BIOPSY

44363 SMALL BOWEL No

ENDOSCOPY

44364 SMALL BOWEL No

ENDOSCOPY

44365 SMALL BOWEL No

ENDOSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 636 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44366 SMALL BOWEL No

ENDOSCOPY

44369 SMALL BOWEL No

ENDOSCOPY

44370 SMALL BOWEL No

ENDOSCOPY/STENT

44372 SMALL BOWEL No

ENDOSCOPY

44373 SMALL BOWEL No

ENDOSCOPY

44376 SMALL BOWEL No

ENDOSCOPY

44377 SMALL BOWEL No

ENDOSCOPY/BIOPSY

44378 SMALL BOWEL No

ENDOSCOPY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 637 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44379 S BOWEL ENDOSCOPE No

W/STENT

44380 SMALL BOWEL No

ENDOSCOPY BR/WA

44381 SMALL BOWEL No

ENDOSCOPY BR/WA

44382 SMALL BOWEL No

ENDOSCOPY

44384 SMALL BOWEL No

ENDOSCOPY

44385 ENDOSCOPY OF BOWEL No

POUCH

44386 ENDOSCOPY BOWEL No

POUCH/BIOP

44388 COLONOSCOPY THRU No

STOMA SPX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 638 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44389 COLONOSCOPY WITH No

BIOPSY

44390 COLONOSCOPY FOR No

FOREIGN BODY

44391 COLONOSCOPY FOR No

BLEEDING

44392 COLONOSCOPY & No

POLYPECTOMY

44394 COLONOSCOPY W/SNARE No

44401 COLONOSCOPY WITH No

ABLATION

44402 COLONOSCOPY W/STENT No

PLCMT

44403 COLONOSCOPY No
W/RESECTION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 639 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44404 COLONOSCOPY No
W/INJECTION

44405 COLONOSCOPY No
W/DILATION

44406 COLONOSCOPY No
W/ULTRASOUND

44407 COLONOSCOPY W/NDL No

ASPIR/BX

44408 COLONOSCOPY No
W/DECOMPRESSION

44500 INTRO No
GASTROINTESTINAL TUBE

44602 SUTURE SMALL INTESTINE No

44603 SUTURE SMALL INTESTINE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 640 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44604 SUTURE LARGE INTESTINE No

44605 REPAIR OF BOWEL LESION No

44615 INTESTINAL No
STRICTUROPLASTY

44620 REPAIR BOWEL OPENING No

44625 REPAIR BOWEL OPENING No

44626 REPAIR BOWEL OPENING No

44640 REPAIR BOWEL-SKIN No

FISTULA

44650 REPAIR BOWEL FISTULA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 641 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44660 REPAIR BOWEL-BLADDER No

FISTULA

44661 REPAIR BOWEL-BLADDER No

FISTULA

44680 SURGICAL REVISION No

INTESTINE

44700 SUSPEND BOWEL No

W/PROSTHESIS

44701 INTRAOP COLON LAVAGE No

ADD-ON

44705 PREPARE FECAL No

MICROBIOTA

44715 PREPARE DONOR No

INTESTINE

44720 PREP DONOR No

INTESTINE/VENOUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 642 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44721 PREP DONOR No

INTESTINE/ARTERY

44799 UNLISTED PX SMALL No* *PA req'd if performed as elective proc in

INTESTINE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

44800 EXCISION OF BOWEL No

POUCH

44820 EXCISION OF MESENTERY No

LESION

44850 REPAIR OF MESENTERY No

44899 BOWEL SURGERY No

PROCEDURE

44900 DRAIN APPENDIX No

ABSCESS OPEN

44950 APPENDECTOMY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 643 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

44955 APPENDECTOMY ADD-ON No

44960 APPENDECTOMY No

44970 LAPAROSCOPY No
APPENDECTOMY

44979 LAPAROSCOPE PROC APP No

45000 DRAINAGE OF PELVIC No

ABSCESS

45005 DRAINAGE OF RECTAL No

ABSCESS

45020 DRAINAGE OF RECTAL No

ABSCESS

45100 BIOPSY OF RECTUM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 644 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45108 REMOVAL OF No
ANORECTAL LESION

45110 REMOVAL OF RECTUM No

45111 PARTIAL REMOVAL OF No

RECTUM

45112 REMOVAL OF RECTUM No

45113 PARTIAL PROCTECTOMY No

45114 PARTIAL REMOVAL OF No

RECTUM

45116 PARTIAL REMOVAL OF No

RECTUM

45119 REMOVE RECTUM No

W/RESERVOIR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 645 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45120 REMOVAL OF RECTUM No

45121 REMOVAL OF RECTUM No

AND COLON

45123 PARTIAL PROCTECTOMY No

45126 PELVIC EXENTERATION No

45130 EXCISION OF RECTAL No

PROLAPSE

45135 EXCISION OF RECTAL No

PROLAPSE

45136 EXCISE ILEOANAL No

RESERVIOR

45150 EXCISION OF RECTAL No

STRICTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 646 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45160 EXCISION OF RECTAL No

LESION

45171 EXC RECT TUM No

TRANSANAL PART

45172 EXC RECT TUM No

TRANSANAL FULL

45190 DESTRUCTION RECTAL No

TUMOR

45300 PROCTOSIGMOIDOSCOPY No
DX

45303 PROCTOSIGMOIDOSCOPY No
DILATE

45305 PROCTOSIGMOIDOSCOPY No
W/BX

45307 PROCTOSIGMOIDOSCOPY No
FB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 647 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45308 PROCTOSIGMOIDOSCOPY No
REMOVAL

45309 PROCTOSIGMOIDOSCOPY No
REMOVAL

45315 PROCTOSIGMOIDOSCOPY No
REMOVAL

45317 PROCTOSIGMOIDOSCOPY No
BLEED

45320 PROCTOSIGMOIDOSCOPY No
ABLATE

45321 PROCTOSIGMOIDOSCOPY No
VOLVUL

45327 PROCTOSIGMOIDOSCOPY No
W/STENT

45330 DIAGNOSTIC No* *PA req'd if performed as elective proc in

SIGMOIDOSCOPY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 648 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45331 SIGMOIDOSCOPY AND No* *PA req'd if performed as elective proc in

BIOPSY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45332 SIGMOIDOSCOPY W/FB No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45333 SIGMOIDOSCOPY & No* *PA req'd if performed as elective proc in

POLYPECTOMY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45334 SIGMOIDOSCOPY FOR No* *PA req'd if performed as elective proc in

BLEEDING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45335 SIGMOIDOSCOPY No* *PA req'd if performed as elective proc in

W/SUBMUC INJ the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45337 SIGMOIDOSCOPY & No* *PA req'd if performed as elective proc in

DECOMPRESS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45338 SIGMOIDOSCOPY No* *PA req'd if performed as elective proc in

W/TUMR REMOVE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45340 SIG W/TNDSC BALLOON No* *PA req'd if performed as elective proc in
DILATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 649 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45341 SIGMOIDOSCOPY No* *PA req'd if performed as elective proc in

W/ULTRASOUND the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45342 SIGMOIDOSCOPY W/US No* *PA req'd if performed as elective proc in

GUIDE BX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45346 SIGMOIDOSCOPY No
W/ABLATION

45347 SIGMOIDOSCOPY No
W/PLCMT STENT

45349 SIGMOIDOSCOPY No
W/RESECTION

45350 SGMDSC W/BAND No

LIGATION

45378 DIAGNOSTIC No* *PA req'd if performed as elective proc in

COLONOSCOPY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45379 COLONOSCOPY W/FB No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 650 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45380 COLONOSCOPY AND No* *PA req'd if performed as elective proc in

BIOPSY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45381 COLONOSCOPY No* *PA req'd if performed as elective proc in

SUBMUCOUS NJX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45382 COLONOSCOPY No* *PA req'd if performed as elective proc in

W/CONTROL BLEED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45384 COLONOSCOPY No* *PA req'd if performed as elective proc in

W/LESION REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45385 COLONOSCOPY No* *PA req'd if performed as elective proc in

W/LESION REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45386 COLONOSCOPY No
W/BALLOON DILAT

45388 COLONOSCOPY No
W/ABLATION

45389 COLONOSCOPY W/STENT No

PLCMT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 651 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45390 COLONOSCOPY No
W/RESECTION

45391 COLONOSCOPY No* *PA req'd if performed as elective proc in

W/ENDOSCOPE US the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45392 COLONOSCOPY No* *PA req'd if performed as elective proc in

W/ENDOSCOPIC FNB the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

45393 COLONOSCOPY No
W/DECOMPRESSION

45395 LAP REMOVAL OF No

RECTUM

45397 LAP REMOVE RECTUM No

W/POUCH

45398 COLONOSCOPY W/BAND No

LIGATION

45399 UNLISTED PROCEDURE No

COLON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 652 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45400 LAPAROSCOPIC PROC No

45402 LAP PROCTOPEXY W/SIG No

RESECT

45499 LAPAROSCOPE PROC No

RECTUM

45500 REPAIR OF RECTUM No

45505 REPAIR OF RECTUM No

45520 TREATMENT OF RECTAL No

PROLAPSE

45540 CORRECT RECTAL No

PROLAPSE

45541 CORRECT RECTAL No

PROLAPSE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 653 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45550 REPAIR No
RECTUM/REMOVE
SIGMOID

45560 REPAIR OF RECTOCELE No

45562 EXPLORATION/REPAIR OF No
RECTUM

45563 EXPLORATION/REPAIR OF No
RECTUM

45800 REPAIR RECT/BLADDER No

FISTULA

45805 REPAIR FISTULA No

W/COLOSTOMY

45820 REPAIR RECTOURETHRAL No

FISTULA

45825 REPAIR FISTULA No

W/COLOSTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 654 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

45900 REDUCTION OF RECTAL No

PROLAPSE

45905 DILATION OF ANAL No

SPHINCTER

45910 DILATION OF RECTAL No

NARROWING

45915 REMOVE RECTAL No

OBSTRUCTION

45990 SURG DX EXAM No

ANORECTAL

45999 RECTUM SURGERY No

PROCEDURE

46020 PLACEMENT OF SETON No

46030 REMOVAL OF RECTAL No

MARKER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 655 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46040 INCISION OF RECTAL No

ABSCESS

46045 INCISION OF RECTAL No

ABSCESS

46050 INCISION OF ANAL No

ABSCESS

46060 INCISION OF RECTAL No

ABSCESS

46070 INCISION OF ANAL No

SEPTUM

46080 INCISION OF ANAL No

SPHINCTER

46083 INCISE EXTERNAL No

HEMORRHOID

46200 REMOVAL OF ANAL No

FISSURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 656 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46220 EXCISE ANAL EXT No

TAG/PAPILLA

46221 LIGATION OF No* *PA req'd if performed as elective proc in

HEMORRHOID(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46230 REMOVAL OF ANAL TAGS No

46250 REMOVE EXT HEM No* *PA req'd if performed as elective proc in
GROUPS 2+ the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46255 REMOVE INT/EXT HEM 1 No* *PA req'd if performed as elective proc in
GROUP the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46257 REMOVE IN/EX HEM GRP No* *PA req'd if performed as elective proc in
& FISS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46258 REMOVE IN/EX HEM GRP No* *PA req'd if performed as elective proc in
W/FISTU the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46260 REMOVE IN/EX HEM No* *PA req'd if performed as elective proc in
GROUPS 2+ the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 657 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46261 REMOVE IN/EX HEM No* *PA req'd if performed as elective proc in
GRPS & FISS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46262 REMOVE IN/EX HEM No* *PA req'd if performed as elective proc in
GRPS W/FIST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46270 REMOVE ANAL FIST SUBQ No

46275 REMOVE ANAL FIST INTER No

46280 REMOVE ANAL FIST No

COMPLEX

46285 REMOVE ANAL FIST 2 No

STAGE

46288 REPAIR ANAL FISTULA No

46320 REMOVAL OF No* *PA req'd if performed as elective proc in

HEMORRHOID CLOT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 658 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46500 INJECTION INTO No* *PA req'd if performed as elective proc in

HEMORRHOID(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46505 CHEMODENERVATION No
ANAL MUSC

46600 DIAGNOSTIC ANOSCOPY No

SPX

46601 DIAGNOSTIC ANOSCOPY No

46604 ANOSCOPY AND DILATION No

46606 ANOSCOPY AND BIOPSY No

46607 DIAGNOSTIC ANOSCOPY No

& BIOPSY

46608 ANOSCOPY REMOVE FOR No

BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 659 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46610 ANOSCOPY REMOVE No

LESION

46611 ANOSCOPY No

46612 ANOSCOPY REMOVE No

LESIONS

46614 ANOSCOPY CONTROL No

BLEEDING

46615 ANOSCOPY No

46700 REPAIR OF ANAL No

STRICTURE

46705 REPAIR OF ANAL No

STRICTURE

46706 REPR OF ANAL FISTULA No

W/GLUE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 660 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46707 REPAIR ANORECTAL FIST No

W/PLUG

46710 REPR PER/VAG POUCH No

SNGL PROC

46712 REPR PER/VAG POUCH No

DBL PROC

46715 REP PERF ANOPER FISTU No

46716 REP PERF No

ANOPER/VESTIB FISTU

46730 CONSTRUCTION OF No
ABSENT ANUS

46735 CONSTRUCTION OF No
ABSENT ANUS

46740 CONSTRUCTION OF No
ABSENT ANUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 661 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46742 REPAIR OF No
IMPERFORATED ANUS

46744 REPAIR OF CLOACAL No

ANOMALY

46746 REPAIR OF CLOACAL No

ANOMALY

46748 REPAIR OF CLOACAL No

ANOMALY

46750 REPAIR OF ANAL No

SPHINCTER

46751 REPAIR OF ANAL No

SPHINCTER

46753 RECONSTRUCTION OF No
ANUS

46754 REMOVAL OF SUTURE No

FROM ANUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 662 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46760 REPAIR OF ANAL No

SPHINCTER

46761 REPAIR OF ANAL No

SPHINCTER

46762 IMPLANT ARTIFICIAL No

SPHINCTER

46900 DESTRUCTION ANAL No

LESION(S)

46910 DESTRUCTION ANAL No

LESION(S)

46916 CRYOSURGERY ANAL No

LESION(S)

46917 LASER SURGERY ANAL No

LESIONS

46922 EXCISION OF ANAL No

LESION(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 663 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

46924 DESTRUCTION ANAL No

LESION(S)

46930 DESTROY INTERNAL No

HEMORRHOIDS

46940 TREATMENT OF ANAL No

FISSURE

46942 TREATMENT OF ANAL No

FISSURE

46945 REMOVE BY LIGAT INT No* *PA req'd if performed as elective proc in
HEM GRP the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46946 REMOVE BY LIGAT INT No* *PA req'd if performed as elective proc in
HEM GRPS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46947 HEMORRHOIDOPEXY BY No* *PA req'd if performed as elective proc in

STAPLING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

46999 ANUS SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 664 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47000 NEEDLE BIOPSY OF LIVER No

47001 NEEDLE BIOPSY LIVER No

ADD-ON

47010 OPEN DRAINAGE LIVER No

LESION

47015 INJECT/ASPIRATE LIVER No

CYST

47100 WEDGE BIOPSY OF LIVER No

47120 PARTIAL REMOVAL OF No

LIVER

47122 EXTENSIVE REMOVAL OF No

LIVER

47125 PARTIAL REMOVAL OF No

LIVER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 665 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47130 PARTIAL REMOVAL OF No

LIVER

47133 REMOVAL OF DONOR No

LIVER

47135 TRANSPLANTATION OF Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ -
LIVER more details
Transplant
Surgery

47140 PARTIAL REMOVAL No

DONOR LIVER

47141 PARTIAL REMOVAL No

DONOR LIVER

47142 PARTIAL REMOVAL No

DONOR LIVER

47143 PREP DONOR LIVER No

WHOLE

47144 PREP DONOR LIVER 3- No

SEGMENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 666 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47145 PREP DONOR LIVER LOBE No

SPLIT

47146 PREP DONOR No

LIVER/VENOUS

47147 PREP DONOR No

LIVER/ARTERIAL

47300 SURGERY FOR LIVER No

LESION

47350 REPAIR LIVER WOUND No

47360 REPAIR LIVER WOUND No

47361 REPAIR LIVER WOUND No

47362 REPAIR LIVER WOUND No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 667 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47370 LAPARO ABLATE LIVER No

TUMOR RF

47371 LAPARO ABLATE LIVER No

CRYOSURG

47379 LAPAROSCOPE No
PROCEDURE LIVER

47380 OPEN ABLATE LIVER No

TUMOR RF

47381 OPEN ABLATE LIVER No

TUMOR CRYO

47382 PERCUT ABLATE LIVER RF No

47383 PERQ ABLTJ LVR No

CRYOABLATION

47399 LIVER SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 668 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47400 INCISION OF LIVER DUCT No

47420 INCISION OF BILE DUCT No

47425 INCISION OF BILE DUCT No

47460 INCISE BILE DUCT No

SPHINCTER

47480 INCISION OF No
GALLBLADDER

47490 INCISION OF No
GALLBLADDER

47531 INJECTION FOR No

CHOLANGIOGRAM

47532 INJECTION FOR No

CHOLANGIOGRAM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 669 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47533 PLMT BILIARY DRAINAGE No

CATH

47534 PLMT BILIARY DRAINAGE No

CATH

47535 CONVERSION EXT BIL No

DRG CATH

47536 EXCHANGE BILIARY DRG No

CATH

47537 REMOVAL BILIARY DRG No

CATH

47538 PERQ PLMT BILE DUCT No

STENT

47539 PERQ PLMT BILE DUCT No

STENT

47540 PERQ PLMT BILE DUCT No

STENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 670 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47541 PLMT ACCESS BIL TREE No

SM BWL

47542 DILATE BILIARY No

DUCT/AMPULLA

47543 ENDOLUMINAL BX No
BILIARY TREE

47544 REMOVAL DUCT GLBLDR No

CALCULI

47550 BILE DUCT ENDOSCOPY No

ADD-ON

47552 BILIARY ENDO PERQ DX No

W/SPECI

47553 BILIARY ENDOSCOPY No

THRU SKIN

47554 BILIARY ENDOSCOPY No

THRU SKIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 671 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47555 BILIARY ENDOSCOPY No

THRU SKIN

47556 BILIARY ENDOSCOPY No

THRU SKIN

47562 LAPAROSCOPIC No* *PA req'd if performed as elective proc in

CHOLECYSTECTOMY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

47563 LAPARO No* *PA req'd if performed as elective proc in

CHOLECYSTECTOMY/GRA the Inpatient setting; incl all clinical
PH documentation that supports the need for
inpatient level of care.

47564 LAPARO No* *PA req'd if performed as elective proc in

CHOLECYSTECTOMY/EXPL the Inpatient setting; incl all clinical
R documentation that supports the need for
inpatient level of care.

47570 LAPARO No
CHOLECYSTOENTEROSTO
MY

47579 LAPAROSCOPE PROC No

BILIARY

47600 REMOVAL OF No
GALLBLADDER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 672 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47605 REMOVAL OF No* *PA req'd if performed as elective proc in

GALLBLADDER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

47610 REMOVAL OF No
GALLBLADDER

47612 REMOVAL OF No
GALLBLADDER

47620 REMOVAL OF No
GALLBLADDER

47700 EXPLORATION OF BILE No

DUCTS

47701 BILE DUCT REVISION No

47711 EXCISION OF BILE DUCT No

TUMOR

47712 EXCISION OF BILE DUCT No

TUMOR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 673 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47715 EXCISION OF BILE DUCT No

CYST

47720 FUSE GALLBLADDER & No

BOWEL

47721 FUSE UPPER GI No

STRUCTURES

47740 FUSE GALLBLADDER & No

BOWEL

47741 FUSE GALLBLADDER & No

BOWEL

47760 FUSE BILE DUCTS AND No

BOWEL

47765 FUSE LIVER DUCTS & No

BOWEL

47780 FUSE BILE DUCTS AND No

BOWEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 674 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

47785 FUSE BILE DUCTS AND No

BOWEL

47800 RECONSTRUCTION OF No
BILE DUCTS

47801 PLACEMENT BILE DUCT No

SUPPORT

47802 FUSE LIVER DUCT & No

INTESTINE

47900 SUTURE BILE DUCT No

INJURY

47999 BILE TRACT SURGERY No

PROCEDURE

48000 DRAINAGE OF ABDOMEN No

48001 PLACEMENT OF DRAIN No

PANCREAS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 675 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

48020 REMOVAL OF No
PANCREATIC STONE

48100 BIOPSY OF PANCREAS No

OPEN

48102 NEEDLE BIOPSY No

PANCREAS

48105 RESECT/DEBRIDE No
PANCREAS

48120 REMOVAL OF PANCREAS No

LESION

48140 PARTIAL REMOVAL OF No

PANCREAS

48145 PARTIAL REMOVAL OF No

PANCREAS

48146 PANCREATECTOMY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 676 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

48148 REMOVAL OF No
PANCREATIC DUCT

48150 PARTIAL REMOVAL OF No

PANCREAS

48152 PANCREATECTOMY No

48153 PANCREATECTOMY No

48154 PANCREATECTOMY No

48155 REMOVAL OF PANCREAS No

48160 PANCREAS Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
NH-Transplant
REMOVAL/TRANSPLANT more details 11/01/18)
Pancreas

48400 INJECTION INTRAOP ADD- No

ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 677 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

48500 SURGERY OF No
PANCREATIC CYST

48510 DRAIN PANCREATIC No

PSEUDOCYST

48520 FUSE PANCREAS CYST No

AND BOWEL

48540 FUSE PANCREAS CYST No

AND BOWEL

48545 PANCREATORRHAPHY No

48547 DUODENAL EXCLUSION No

48548 FUSE PANCREAS AND No

BOWEL

48550 DONOR No
PANCREATECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 678 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

48551 PREP DONOR PANCREAS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

48552 PREP DONOR No

PANCREAS/VENOUS

48554 TRANSPL ALLOGRAFT Yes Please review the Well Sense Policy for Transplantation of Pancreas or Transplantation of Pancreas
NH-Transplant
PANCREAS more details Pancreas-Kidney or Pancreas-Kidney (Eff
Pancreas 04/01/18)

48556 REMOVAL ALLOGRAFT Yes Please review the Well Sense Policy for Transplantation of Pancreas or Transplantation of Pancreas
NH-Transplant
PANCREAS more details Pancreas-Kidney or Pancreas-Kidney (Eff
Pancreas 04/01/18)

48999 PANCREAS SURGERY Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
NH-Transplant
PROCEDURE more details 11/01/18)
Pancreas

49000 EXPLORATION OF No
ABDOMEN

49002 REOPENING OF No
ABDOMEN

49010 EXPLORATION BEHIND No

ABDOMEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 679 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49020 DRAINAGE ABDOM No

ABSCESS OPEN

49040 DRAIN OPEN ABDOM No

ABSCESS

49060 DRAIN OPEN RETROPERI No

ABSCESS

49062 DRAIN TO PERITONEAL No

CAVITY

49082 ABD PARACENTESIS No

49083 ABD PARACENTESIS No

W/IMAGING

49084 PERITONEAL LAVAGE No

49180 BIOPSY ABDOMINAL No* *PA req'd if performed as elective proc in

MASS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 680 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49185 SCLEROTX FLUID No

COLLECTION

49203 EXC ABD TUM 5 CM OR No

LESS

49204 EXC ABD TUM OVER 5 CM No

49205 EXC ABD TUM OVER 10 No

CM

49215 EXCISE SACRAL SPINE No

TUMOR

49220 MULTIPLE SURGERY No

ABDOMEN

49250 EXCISION OF UMBILICUS No

49255 REMOVAL OF OMENTUM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 681 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49320 DIAG LAPARO SEPARATE No* *PA req'd if performed as elective proc in
PROC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49321 LAPAROSCOPY BIOPSY No

49322 LAPAROSCOPY No
ASPIRATION

49323 LAPARO DRAIN No

LYMPHOCELE

49324 LAP INSERT TUNNEL IP No

CATH

49325 LAP REVISION PERM IP No

CATH

49326 LAP W/OMENTOPEXY No

ADD-ON

49327 LAP INS DEVICE FOR RT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 682 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49329 LAPARO PROC No* *PA req'd if performed as elective proc in

ABDM/PER/OMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49400 AIR INJECTION INTO No

ABDOMEN

49402 REMOVE FOREIGN BODY No

ADBOMEN

49405 IMAGE CATH FLUID No

COLXN VISC

49406 IMAGE CATH FLUID No

PERI/RETRO

49407 IMAGE CATH FLUID No

TRNS/VGNL

49411 INS MARK ABD/PEL FOR No

RT PERQ

49412 INS DEVICE FOR RT No

GUIDE OPEN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 683 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49418 INSERT TUN IP CATH PERC No

49419 INSERT TUN IP CATH No

W/PORT

49421 INS TUN IP CATH FOR No

DIAL OPN

49422 REMOVE TUNNELED IP No

CATH

49423 EXCHANGE DRAINAGE No

CATHETER

49424 ASSESS CYST CONTRAST No

INJECT

49425 INSERT ABDOMEN- No

VENOUS DRAIN

49426 REVISE ABDOMEN- No

VENOUS SHUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 684 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49427 INJECTION ABDOMINAL No

SHUNT

49428 LIGATION OF SHUNT No

49429 REMOVAL OF SHUNT No

49435 INSERT SUBQ EXTEN TO No

IP CATH

49436 EMBEDDED IP CATH EXIT- No

SITE

49440 PLACE GASTROSTOMY No

TUBE PERC

49441 PLACE DUOD/JEJ TUBE No

PERC

49442 PLACE CECOSTOMY TUBE No

PERC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 685 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49446 CHANGE G-TUBE TO G-J No

PERC

49450 REPLACE G/C TUBE PERC No

49451 REPLACE DUOD/JEJ TUBE No

PERC

49452 REPLACE G-J TUBE PERC No

49460 FIX G/COLON TUBE No

W/DEVICE

49465 FLUORO EXAM OF No

G/COLON TUBE

49491 RPR HERN PREEMIE No* *PA req'd if performed as elective proc in
REDUC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49492 RPR ING HERN PREMIE No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 686 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49495 RPR ING HERNIA BABY No* *PA req'd if performed as elective proc in
REDUC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49496 RPR ING HERNIA BABY No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49500 RPR ING HERNIA INIT No* *PA req'd if performed as elective proc in
REDUCE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49501 RPR ING HERNIA INIT No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49505 PRP I/HERN INIT REDUC No* *PA req'd if performed as elective proc in
>5 YR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49507 PRP I/HERN INIT BLOCK No* *PA req'd if performed as elective proc in
>5 YR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49520 REREPAIR ING HERNIA No* *PA req'd if performed as elective proc in
REDUCE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49521 REREPAIR ING HERNIA No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 687 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49525 REPAIR ING HERNIA No* *PA req'd if performed as elective proc in
SLIDING the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49540 REPAIR LUMBAR HERNIA No

49550 RPR REM HERNIA INIT No* *PA req'd if performed as elective proc in
REDUCE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49553 RPR FEM HERNIA INIT No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49555 REREPAIR FEM HERNIA No* *PA req'd if performed as elective proc in
REDUCE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49557 REREPAIR FEM HERNIA No* *PA req'd if performed as elective proc in
BLOCKED the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49560 RPR VENTRAL HERN INIT Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
REDUC ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49561 RPR VENTRAL HERN INIT No
BLOCK

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 688 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49565 REREPAIR VENTRL HERN Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
REDUCE ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49566 REREPAIR VENTRL HERN No
BLOCK

49568 HERNIA REPAIR W/MESH Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49570 RPR EPIGASTRIC HERN Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
REDUCE ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49572 RPR EPIGASTRIC HERN No
BLOCKED

49580 RPR UMBIL HERN REDUC No* *PA req'd if performed as elective proc in
< 5 YR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49582 RPR UMBIL HERN BLOCK No* *PA req'd if performed as elective proc in
< 5 YR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49585 RPR UMBIL HERN REDUC Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
> 5 YR ages 4-18 yrs. Otherwise, InterQual®
General criteria used. Will be covered only when
Surgery performed in the Outpatient setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 689 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49587 RPR UMBIL HERN BLOCK No* *PA req'd if performed as elective proc in
> 5 YR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49590 REPAIR SPIGELIAN No

HERNIA

49600 REPAIR UMBILICAL No

LESION

49605 REPAIR UMBILICAL No

LESION

49606 REPAIR UMBILICAL No

LESION

49610 REPAIR UMBILICAL No

LESION

49611 REPAIR UMBILICAL No

LESION

49650 LAP ING HERNIA REPAIR No* *PA req'd if performed as elective proc in
INIT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 690 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49651 LAP ING HERNIA REPAIR No* *PA req'd if performed as elective proc in
RECUR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49652 LAP VENT/ABD HERNIA Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
REPAIR ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Will be covered only when
Surgery performed in the Outpatient setting.

49653 LAP VENT/ABD HERN No* *PA req'd if performed as elective proc in
PROC COMP the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

49654 LAP INC HERNIA REPAIR Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49655 LAP INC HERN REPAIR No
COMP

49656 LAP INC HERNIA REPAIR Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
RECUR ages 0-18 yrs. Otherwise, InterQual®
General criteria used. Provide clinical
Surgery documentation supporting rationale for
request.
49657 LAP INC HERN RECUR No
COMP

49659 LAPARO PROC HERNIA Yes* *NOTE: This code does NOT require PA for
NH-IQ-Other
REPAIR ages 4-18 yrs. Otherwise, InterQual®
General criteria used. Will be covered only when
Surgery performed in the Outpatient setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 691 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

49900 REPAIR OF ABDOMINAL No

WALL

49904 OMENTAL FLAP EXTRA- No

ABDOM

49905 OMENTAL FLAP INTRA- No

ABDOM

49906 FREE OMENTAL FLAP No

MICROVASC

49999 ABDOMEN SURGERY No

PROCEDURE

endocrine system
60000 DRAIN THYROID/TONGUE No
CYST

60100 BIOPSY OF THYROID No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 692 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

60200 REMOVE THYROID LESION No

60210 PARTIAL THYROID No* *PA req'd if performed as elective proc in

EXCISION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60212 PARTIAL THYROID No* *PA req'd if performed as elective proc in

EXCISION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60220 PARTIAL REMOVAL OF No* *PA req'd if performed as elective proc in

THYROID the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60225 PARTIAL REMOVAL OF No* *PA req'd if performed as elective proc in

THYROID the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60240 REMOVAL OF THYROID No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60252 REMOVAL OF THYROID No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60254 EXTENSIVE THYROID No* *PA req'd if performed as elective proc in

SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 693 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

60260 REPEAT THYROID No* *PA req'd if performed as elective proc in

SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60270 REMOVAL OF THYROID No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60271 REMOVAL OF THYROID No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

60280 REMOVE THYROID DUCT Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
LESION more details 11/01/18)
Surg

60281 REMOVE THYROID DUCT Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
LESION more details 11/01/18)
Surg

60300 ASPIR/INJ THYROID CYST No

60500 EXPLORE PARATHYROID No

GLANDS

60502 RE-EXPLORE No
PARATHYROIDS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 694 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

60505 EXPLORE PARATHYROID No

GLANDS

60512 AUTOTRANSPLANT No
PARATHYROID

60520 REMOVAL OF THYMUS No

GLAND

60521 REMOVAL OF THYMUS No

GLAND

60522 REMOVAL OF THYMUS No

GLAND

60540 EXPLORE ADRENAL No

GLAND

60545 EXPLORE ADRENAL No

GLAND

60600 REMOVE CAROTID BODY No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 695 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

60605 REMOVE CAROTID BODY No

LESION

60650 LAPAROSCOPY No
ADRENALECTOMY

60659 LAPARO PROC No

ENDOCRINE

60699 ENDOCRINE SURGERY No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

eye and ocular adnexa

65091 REVISE EYE No

65093 REVISE EYE WITH No

IMPLANT

65101 REMOVAL OF EYE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 696 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65103 REMOVE EYE/INSERT No

IMPLANT

65105 REMOVE EYE/ATTACH No

IMPLANT

65110 REMOVAL OF EYE No

65112 REMOVE EYE/REVISE No

SOCKET

65114 REMOVE EYE/REVISE No

SOCKET

65125 REVISE OCULAR IMPLANT No

65130 INSERT OCULAR IMPLANT No

65135 INSERT OCULAR IMPLANT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 697 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65140 ATTACH OCULAR No

IMPLANT

65150 REVISE OCULAR IMPLANT No

65155 REINSERT OCULAR No

IMPLANT

65175 REMOVAL OF OCULAR No

IMPLANT

65205 REMOVE FOREIGN BODY No

FROM EYE

65210 REMOVE FOREIGN BODY No

FROM EYE

65220 REMOVE FOREIGN BODY No

FROM EYE

65222 REMOVE FOREIGN BODY No

FROM EYE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 698 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65235 REMOVE FOREIGN BODY No

FROM EYE

65260 REMOVE FOREIGN BODY No

FROM EYE

65265 REMOVE FOREIGN BODY No

FROM EYE

65270 REPAIR OF EYE WOUND No

65272 REPAIR OF EYE WOUND No

65273 REPAIR OF EYE WOUND No

65275 REPAIR OF EYE WOUND No

65280 REPAIR OF EYE WOUND No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 699 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65285 REPAIR OF EYE WOUND No

65286 REPAIR OF EYE WOUND No

65290 REPAIR OF EYE SOCKET No

WOUND

65400 REMOVAL OF EYE LESION No

65410 BIOPSY OF CORNEA No

65420 REMOVAL OF EYE LESION Yes Provide clinical documentation supporting

IQ - Eye
rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

65426 REMOVAL OF EYE LESION Yes Provide clinical documentation supporting

IQ - Eye
rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

65430 CORNEAL SMEAR No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 700 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65435 CURETTE/TREAT CORNEA No

65436 CURETTE/TREAT CORNEA No

65450 TREATMENT OF No
CORNEAL LESION

65600 REVISION OF CORNEA No

65710 CORNEAL TRANSPLANT No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

65730 CORNEAL TRANSPLANT No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

65750 CORNEAL TRANSPLANT No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

65755 CORNEAL TRANSPLANT No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 701 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65756 CORNEAL TRNSPL Yes* Please review BMCHP criteria for details. InterQual® criteria is available
ENDOTHELIAL *Will be covered only when performed in
the Outpatient setting.

65757 PREP CORNEAL ENDO Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ALLOGRAFT more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

65760 REVISION OF CORNEA No

65765 REVISION OF CORNEA No

65767 CORNEAL TISSUE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
TRANSPLANT *Will be covered only when performed in
the Outpatient setting.

65770 REVISE CORNEA WITH No

IMPLANT

65771 RADIAL KERATOTOMY No

65772 CORRECTION OF No
ASTIGMATISM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 702 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65775 CORRECTION OF No
ASTIGMATISM

65778 COVER EYE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
W/MEMBRANE more details Treatment Investigational Treatmen
Experimental/I
nvestigation

65779 COVER EYE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
W/MEMBRANE SUTURE more details Treatment Investigational Treatmen
Experimental/I
nvestigation

65780 OCULAR RECONST No

TRANSPLANT

65781 OCULAR RECONST No

TRANSPLANT

65782 OCULAR RECONST No

TRANSPLANT

65785 IMPLTJ NTRSTRML CRNL No

RNG SEG

65800 DRAINAGE OF EYE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 703 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65810 DRAINAGE OF EYE No

65815 DRAINAGE OF EYE No

65820 RELIEVE INNER EYE No

PRESSURE

65850 INCISION OF EYE No

65855 TRABECULOPLASTY No* *PA req'd if performed as elective proc in

LASER SURG the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

65860 INCISE INNER EYE No

ADHESIONS

65865 INCISE INNER EYE No

ADHESIONS

65870 INCISE INNER EYE No

ADHESIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 704 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

65875 INCISE INNER EYE No

ADHESIONS

65880 INCISE INNER EYE No

ADHESIONS

65900 REMOVE EYE LESION No

65920 REMOVE IMPLANT OF EYE No

65930 REMOVE BLOOD CLOT No

FROM EYE

66020 INJECTION TREATMENT No

OF EYE

66030 INJECTION TREATMENT No

OF EYE

66130 REMOVE EYE LESION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 705 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66150 GLAUCOMA SURGERY No

66155 GLAUCOMA SURGERY No

66160 GLAUCOMA SURGERY No

66170 GLAUCOMA SURGERY No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66172 INCISION OF EYE No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66174 TRANSLUM DIL EYE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
CANAL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

66175 TRNSLUM DIL EYE CANAL No

W/STNT

66179 AQUEOUS SHUNT EYE No

W/O GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 706 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66180 AQUEOUS SHUNT EYE No

W/GRAFT

66183 INSERT ANT DRAINAGE No

DEVICE

66184 REVISION OF AQUEOUS No

SHUNT

66185 REVISE AQUEOUS SHUNT No

EYE

66220 REPAIR EYE LESION No

66225 REPAIR/GRAFT EYE No

LESION

66250 FOLLOW-UP SURGERY OF No

EYE

66500 INCISION OF IRIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 707 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66505 INCISION OF IRIS No

66600 REMOVE IRIS AND LESION No

66605 REMOVAL OF IRIS No

66625 REMOVAL OF IRIS No

66630 REMOVAL OF IRIS No

66635 REMOVAL OF IRIS No

66680 REPAIR IRIS & CILIARY No

BODY

66682 REPAIR IRIS & CILIARY No

BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 708 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66700 DESTRUCTION CILIARY No

BODY

66710 CILIARY TRANSSLERAL No

THERAPY

66711 CILIARY ENDOSCOPIC No

ABLATION

66720 DESTRUCTION CILIARY No

BODY

66740 DESTRUCTION CILIARY No

BODY

66761 REVISION OF IRIS No

66762 REVISION OF IRIS No

66770 REMOVAL OF INNER EYE No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 709 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66820 INCISION SECONDARY No* *PA req'd if performed as elective proc in

CATARACT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66821 AFTER CATARACT LASER No* *PA req'd if performed as elective proc in
SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66825 REPOSITION No
INTRAOCULAR LENS

66830 REMOVAL OF LENS No

LESION

66840 REMOVAL OF LENS No* *PA req'd if performed as elective proc in

MATERIAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66850 REMOVAL OF LENS No* *PA req'd if performed as elective proc in

MATERIAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66852 REMOVAL OF LENS No* *PA req'd if performed as elective proc in

MATERIAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66920 EXTRACTION OF LENS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 710 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66930 EXTRACTION OF LENS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66940 EXTRACTION OF LENS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66982 CATARACT SURGERY No* *PA req'd if performed as elective proc in

COMPLEX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66983 CATARACT SURG W/IOL 1 No* *PA req'd if performed as elective proc in
STAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66984 CATARACT SURG W/IOL 1 No* *PA req'd if performed as elective proc in
STAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

66985 INSERT LENS PROSTHESIS No

66986 EXCHANGE LENS No

PROSTHESIS

66990 OPHTHALMIC No
ENDOSCOPE ADD-ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 711 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

66999 EYE SURGERY No

PROCEDURE

67005 PARTIAL REMOVAL OF No

EYE FLUID

67010 PARTIAL REMOVAL OF No

EYE FLUID

67015 RELEASE OF EYE FLUID No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67025 REPLACE EYE FLUID No

67027 IMPLANT EYE DRUG No

SYSTEM

67028 INJECTION EYE DRUG No

67030 INCISE INNER EYE No* *PA req'd if performed as elective proc in
STRANDS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 712 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67031 LASER SURGERY EYE No

STRANDS

67036 REMOVAL OF INNER EYE No* *PA req'd if performed as elective proc in
FLUID the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67039 LASER TREATMENT OF No* *PA req'd if performed as elective proc in

RETINA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67040 LASER TREATMENT OF No* *PA req'd if performed as elective proc in

RETINA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67041 VIT FOR MACULAR No* *PA req'd if performed as elective proc in
PUCKER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67042 VIT FOR MACULAR HOLE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67043 VIT FOR MEMBRANE No* *PA req'd if performed as elective proc in
DISSECT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67101 REPAIR DETACHED No

RETINA CRTX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 713 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67105 REPAIR DETACHED No

RETINA PC

67107 REPAIR DETACHED No

RETINA

67108 REPAIR DETACHED No* *PA req'd if performed as elective proc in

RETINA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67110 REPAIR DETACHED No

RETINA

67113 REPAIR RETINAL DETACH No* *PA req'd if performed as elective proc in
CPLX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67115 RELEASE ENCIRCLING No

MATERIAL

67120 REMOVE EYE IMPLANT No

MATERIAL

67121 REMOVE EYE IMPLANT No

MATERIAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 714 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67141 TREATMENT OF RETINA No

67145 TREATMENT OF RETINA No

67208 TREATMENT OF RETINAL No

LESION

67210 TREATMENT OF RETINAL No* *PA req'd if performed as elective proc in

LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67218 TREATMENT OF RETINAL No

LESION

67220 TREATMENT OF No* *PA req'd if performed as elective proc in

CHOROID LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67221 OCULAR No
PHOTODYNAMIC THER

67225 EYE PHOTODYNAMIC No

THER ADD-ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 715 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67227 DSTRJ EXTENSIVE No

RETINOPATHY

67228 TREATMENT X10SV No* *PA req'd if performed as elective proc in

RETINOPATHY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67229 TR RETINAL LES PRETERM No

INF

67250 REINFORCE EYE WALL No

67255 REINFORCE/GRAFT EYE No

WALL

67299 EYE SURGERY No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67311 REVISE EYE MUSCLE Yes* *NOTE: This code does NOT require PA for
IQ - Eye
ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67312 REVISE TWO EYE Yes* *NOTE: This code does NOT require PA for
IQ - Eye
MUSCLES ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 716 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67314 REVISE EYE MUSCLE Yes* *NOTE: This code does NOT require PA for
IQ - Eye
ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67316 REVISE TWO EYE Yes* *NOTE: This code does NOT require PA for
IQ - Eye
MUSCLES ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67318 REVISE EYE MUSCLE(S) Yes* *NOTE: This code does NOT require PA for
IQ - Eye
ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67320 REVISE EYE MUSCLE(S) No
ADD-ON

67331 EYE SURGERY FOLLOW- No

UP ADD-ON

67332 REREVISE EYE MUSCLES Yes* *NOTE: This code does NOT require PA for
IQ - Eye
ADD-ON ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67334 REVISE EYE MUSCLE No
W/SUTURE

67335 EYE SUTURE DURING No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 717 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67340 REVISE EYE MUSCLE ADD- No

ON

67343 RELEASE EYE TISSUE Yes* *NOTE: This code does NOT require PA for
IQ - Eye
ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
67345 DESTROY NERVE OF EYE No
MUSCLE

67346 BIOPSY EYE MUSCLE No

67399 UNLISTED PX No
EXTRAOCULAR MUSC

67400 EXPLORE/BIOPSY EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67405 EXPLORE/DRAIN EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67412 EXPLORE/TREAT EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 718 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67413 EXPLORE/TREAT EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67414 EXPLR/DECOMPRESS EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67415 ASPIRATION ORBITAL No

CONTENTS

67420 EXPLORE/TREAT EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67430 EXPLORE/TREAT EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67440 EXPLORE/DRAIN EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67445 EXPLR/DECOMPRESS EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67450 EXPLORE/BIOPSY EYE No* *PA req'd if performed as elective proc in

SOCKET the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 719 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67500 INJECT/TREAT EYE No

SOCKET

67505 INJECT/TREAT EYE No

SOCKET

67515 INJECT/TREAT EYE No

SOCKET

67550 INSERT EYE SOCKET No

IMPLANT

67560 REVISE EYE SOCKET No

IMPLANT

67570 DECOMPRESS OPTIC No

NERVE

67599 ORBIT SURGERY No

PROCEDURE

67700 DRAINAGE OF EYELID No

ABSCESS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 720 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67710 INCISION OF EYELID No

67715 INCISION OF EYELID FOLD No

67800 REMOVE EYELID LESION Yes* InterQual® criteria used. *Will be covered
IQ - Eye
only when performed in the Outpatient
Surgery setting.

67801 REMOVE EYELID LESIONS Yes* InterQual® criteria used. *Will be covered
IQ - Eye
only when performed in the Outpatient
Surgery setting.

67805 REMOVE EYELID LESIONS Yes* InterQual® criteria used. *Will be covered
IQ - Eye
only when performed in the Outpatient
Surgery setting.

67808 REMOVE EYELID No* *PA req'd if performed as elective proc in

LESION(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67810 BIOPSY EYELID & LID Yes* InterQual® criteria used. *Will be covered
IQ - Eye
MARGIN only when performed in the Outpatient
Surgery setting.

67820 REVISE EYELASHES No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 721 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67825 REVISE EYELASHES No

67830 REVISE EYELASHES No

67835 REVISE EYELASHES No

67840 REMOVE EYELID LESION Yes* InterQual® criteria used. *Will be covered
IQ - Eye
only when performed in the Outpatient
Surgery setting.

67850 TREAT EYELID LESION No

67875 CLOSURE OF EYELID BY No

SUTURE

67880 REVISION OF EYELID No

67882 REVISION OF EYELID No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 722 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67900 REPAIR BROW DEFECT Yes Provide clinical documentation supporting Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ - Eye
rationale for request (e.g., notes, lab Restorative Services and Restorative Services (Eff
Surgery values, X-rays, etc.) 07/01/18)

67901 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67902 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67903 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67904 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67906 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67908 REPAIR EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

67909 REVISE EYELID DEFECT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
*Will be covered only when performed in
Surgery the Outpatient setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 723 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67911 REVISE EYELID DEFECT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

67912 CORRECTION EYELID Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
W/IMPLANT more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

67914 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67915 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67916 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67917 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67921 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67922 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 724 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67923 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67924 REPAIR EYELID DEFECT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

67930 REPAIR EYELID WOUND No

67935 REPAIR EYELID WOUND No

67938 REMOVE EYELID No

FOREIGN BODY

67950 REVISION OF EYELID No

67961 REVISION OF EYELID Yes* InterQual® criteria used. *Will be covered

IQ - Eye
only when performed in the Outpatient
Surgery setting.

67966 REVISION OF EYELID Yes* InterQual® criteria used. *Will be covered

IQ - Eye
only when performed in the Outpatient
Surgery setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 725 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

67971 RECONSTRUCTION OF Yes* InterQual® criteria used. *Will be covered

IQ - Eye
EYELID only when performed in the Outpatient
Surgery setting.

67973 RECONSTRUCTION OF Yes* InterQual® criteria used. *Will be covered

IQ - Eye
EYELID only when performed in the Outpatient
Surgery setting.

67974 RECONSTRUCTION OF Yes* InterQual® criteria used. *Will be covered

IQ - Eye
EYELID only when performed in the Outpatient
Surgery setting.

67975 RECONSTRUCTION OF Yes* InterQual® criteria used. *Will be covered

IQ - Eye
EYELID only when performed in the Outpatient
Surgery setting.

67999 REVISION OF EYELID No

68020 INCISE/DRAIN EYELID No

LINING

68040 TREATMENT OF EYELID No

LESIONS

68100 BIOPSY OF EYELID LINING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 726 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68110 REMOVE EYELID LINING No

LESION

68115 REMOVE EYELID LINING No

LESION

68130 REMOVE EYELID LINING No

LESION

68135 REMOVE EYELID LINING No

LESION

68200 TREAT EYELID BY No

INJECTION

68320 REVISE/GRAFT EYELID No

LINING

68325 REVISE/GRAFT EYELID No

LINING

68326 REVISE/GRAFT EYELID No

LINING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 727 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68328 REVISE/GRAFT EYELID No

LINING

68330 REVISE EYELID LINING No

68335 REVISE/GRAFT EYELID No

LINING

68340 SEPARATE EYELID No

ADHESIONS

68360 REVISE EYELID LINING No

68362 REVISE EYELID LINING No

68371 HARVEST EYE TISSUE No

ALOGRAFT

68399 EYELID LINING SURGERY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 728 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68400 INCISE/DRAIN TEAR No

GLAND

68420 INCISE/DRAIN TEAR SAC No

68440 INCISE TEAR DUCT No

OPENING

68500 REMOVAL OF TEAR No

GLAND

68505 PARTIAL REMOVAL TEAR No

GLAND

68510 BIOPSY OF TEAR GLAND No

68520 REMOVAL OF TEAR SAC No

68525 BIOPSY OF TEAR SAC No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 729 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68530 CLEARANCE OF TEAR No

DUCT

68540 REMOVE TEAR GLAND No

LESION

68550 REMOVE TEAR GLAND No

LESION

68700 REPAIR TEAR DUCTS No

68705 REVISE TEAR DUCT No

OPENING

68720 CREATE TEAR SAC DRAIN No

68745 CREATE TEAR DUCT No

DRAIN

68750 CREATE TEAR DUCT No

DRAIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 730 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68760 CLOSE TEAR DUCT No

OPENING

68761 CLOSE TEAR DUCT No

OPENING

68770 CLOSE TEAR SYSTEM No

FISTULA

68801 DILATE TEAR DUCT No

OPENING

68810 PROBE NASOLACRIMAL No

DUCT

68811 PROBE NASOLACRIMAL No

DUCT

68815 PROBE NASOLACRIMAL No

DUCT

68816 PROBE NL DUCT No

W/BALLOON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 731 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

68840 EXPLORE/IRRIGATE TEAR No

DUCTS

68850 INJECTION FOR TEAR SAC No

X-RAY

68899 TEAR DUCT SYSTEM No

SURGERY

general
10021 FNA W/O IMAGE No

10022 FNA W/IMAGE No

hemic and lymphatic systems

38100 REMOVAL OF SPLEEN No
TOTAL

38101 REMOVAL OF SPLEEN No

PARTIAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 732 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38102 REMOVAL OF SPLEEN No

TOTAL

38115 REPAIR OF RUPTURED No

SPLEEN

38120 LAPAROSCOPY No
SPLENECTOMY

38129 LAPAROSCOPE PROC No

SPLEEN

38200 INJECTION FOR SPLEEN X- No

RAY

38204 BL DONOR SEARCH No

MANAGEMENT

38205 HARVEST ALLOGENEIC No

STEM CELL

38206 HARVEST AUTO STEM No

CELLS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 733 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38207 CRYOPRESERVE STEM No

CELLS

38208 THAW PRESERVED STEM No

CELLS

38209 WASH HARVEST STEM No

CELLS

38210 T-CELL DEPLETION OF No

HARVEST

38211 TUMOR CELL DEPLETE OF No

HARVST

38212 RBC DEPLETION OF No

HARVEST

38213 PLATELET DEPLETE OF No

HARVEST

38214 VOLUME DEPLETE OF No

HARVEST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 734 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38215 HARVEST STEM CELL No

CONCENTRTE

38220 BONE MARROW No

ASPIRATION

38221 BONE MARROW BIOPSY No

38230 BONE MARROW No

HARVEST ALLOGEN

38232 BONE MARROW Yes InterQual® criteria used. Provide clinical

IQ -
HARVEST AUTOLOG documentation supporting rationale for
Transplant request (e.g., notes, lab values, X-rays, etc.)
Surgery

38240 TRANSPLT ALLO Yes InterQual® criteria used. Provide clinical

IQ -
HCT/DONOR documentation supporting rationale for
Transplant request (e.g., notes, lab values, X-rays, etc.)
Surgery

38241 TRANSPLT AUTOL Yes* InterQual® criteria used. *Will be covered

IQ -
HCT/DONOR only when performed in the Outpatient
Transplant setting.
Surgery

38242 TRANSPLT ALLO No

LYMPHOCYTES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 735 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38243 TRANSPLJ No
HEMATOPOIETIC BOOST

38300 DRAINAGE LYMPH NODE No

LESION

38305 DRAINAGE LYMPH NODE No

LESION

38308 INCISION OF LYMPH No

CHANNELS

38380 THORACIC DUCT No

PROCEDURE

38381 THORACIC DUCT No

PROCEDURE

38382 THORACIC DUCT No

PROCEDURE

38500 BIOPSY/REMOVAL No* *PA req'd if performed as elective proc in

LYMPH NODES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 736 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38505 NEEDLE BIOPSY LYMPH No

NODES

38510 BIOPSY/REMOVAL No
LYMPH NODES

38520 BIOPSY/REMOVAL No
LYMPH NODES

38525 BIOPSY/REMOVAL No* *PA req'd if performed as elective proc in

LYMPH NODES the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

38530 BIOPSY/REMOVAL No
LYMPH NODES

38542 EXPLORE DEEP NODE(S) No

NECK

38550 REMOVAL NECK/ARMPIT No

LESION

38555 REMOVAL NECK/ARMPIT No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 737 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38562 REMOVAL PELVIC LYMPH No

NODES

38564 REMOVAL ABDOMEN No

LYMPH NODES

38570 LAPAROSCOPY LYMPH No

NODE BIOP

38571 LAPAROSCOPY No
LYMPHADENECTOMY

38572 LAPAROSCOPY No
LYMPHADENECTOMY

38589 LAPAROSCOPE PROC No

LYMPHATIC

38700 REMOVAL OF LYMPH No

NODES NECK

38720 REMOVAL OF LYMPH No

NODES NECK

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 738 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38724 REMOVAL OF LYMPH No

NODES NECK

38740 REMOVE ARMPIT LYMPH No

NODES

38745 REMOVE ARMPIT LYMPH No

NODES

38746 REMOVE THORACIC No

LYMPH NODES

38747 REMOVE ABDOMINAL No

LYMPH NODES

38760 REMOVE GROIN LYMPH No

NODES

38765 REMOVE GROIN LYMPH No

NODES

38770 REMOVE PELVIS LYMPH No

NODES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 739 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

38780 REMOVE ABDOMEN No

LYMPH NODES

38790 INJECT FOR LYMPHATIC X- No

RAY

38792 RA TRACER ID OF No
SENTINL NODE

38794 ACCESS THORACIC No

LYMPH DUCT

38900 IO MAP OF SENT LYMPH No

NODE

38999 BLOOD/LYMPH SYSTEM No

PROCEDURE

integumentary system
10030 GUIDE CATHET FLUID No
DRAINAGE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 740 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

10035 PERQ DEV SOFT TISS 1ST No

IMAG

10036 PERQ DEV SOFT TISS ADD No

IMAG

10040 ACNE SURGERY No

10060 DRAINAGE OF SKIN No

ABSCESS

10061 DRAINAGE OF SKIN No

ABSCESS

10080 DRAINAGE OF PILONIDAL No

CYST

10081 DRAINAGE OF PILONIDAL No

CYST

10120 REMOVE FOREIGN BODY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 741 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

10121 REMOVE FOREIGN BODY No

10140 DRAINAGE OF No
HEMATOMA/FLUID

10160 PUNCTURE DRAINAGE OF No

LESION

10180 COMPLEX DRAINAGE No

WOUND

11000 DEBRIDE INFECTED SKIN No

11001 DEBRIDE INFECTED SKIN No

ADD-ON

11004 DEBRIDE GENITALIA & No

PERINEUM

11005 DEBRIDE ABDOM WALL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 742 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11006 DEBRIDE No
GENIT/PER/ABDOM WALL

11008 REMOVE MESH FROM No

ABD WALL

11010 DEBRIDE SKIN AT FX SITE No

11011 DEBRIDE SKIN MUSC AT No

FX SITE

11012 DEB SKIN BONE AT FX SITE No

11042 DEB SUBQ TISSUE 20 SQ No* *PA req'd if performed as elective proc in
CM/< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11043 DEB MUSC/FASCIA 20 SQ No* *PA req'd if performed as elective proc in

CM/< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11044 DEB BONE 20 SQ CM/< No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 743 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11045 DEB SUBQ TISSUE ADD- No

ON

11046 DEB MUSC/FASCIA ADD- No

ON

11047 DEB BONE ADD-ON No

11055 TRIM SKIN LESION No

11056 TRIM SKIN LESIONS 2 TO 4 No

11057 TRIM SKIN LESIONS OVER No

4

11100 BIOPSY SKIN LESION No

11101 BIOPSY SKIN ADD-ON No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 744 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11200 REMOVAL OF SKIN TAGS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
<W/15 more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11201 REMOVE SKIN TAGS ADD- Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ON more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11300 SHAVE SKIN LESION 0.5 No

CM/<

11301 SHAVE SKIN LESION 0.6- No

1.0 CM

11302 SHAVE SKIN LESION 1.1- No

2.0 CM

11303 SHAVE SKIN LESION >2.0 No

CM

11305 SHAVE SKIN LESION 0.5 No

CM/<

11306 SHAVE SKIN LESION 0.6- No

1.0 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 745 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11307 SHAVE SKIN LESION 1.1- No

2.0 CM

11308 SHAVE SKIN LESION >2.0 No

CM

11310 SHAVE SKIN LESION 0.5 No

CM/<

11311 SHAVE SKIN LESION 0.6- No

1.0 CM

11312 SHAVE SKIN LESION 1.1- No

2.0 CM

11313 SHAVE SKIN LESION >2.0 No

CM

11400 EXC TR-EXT B9+MARG 0.5 No* *PA req'd if performed as elective proc in
CM< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11401 EXC TR-EXT B9+MARG No* *PA req'd if performed as elective proc in
0.6-1 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 746 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11402 EXC TR-EXT B9+MARG No* *PA req'd if performed as elective proc in
1.1-2 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11403 EXC TR-EXT B9+MARG No* *PA req'd if performed as elective proc in
2.1-3CM/< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11404 EXC TR-EXT B9+MARG No* *PA req'd if performed as elective proc in
3.1-4 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11406 EXC TR-EXT B9+MARG No* *PA req'd if performed as elective proc in
>4.0 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11420 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
0.5/< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11421 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
0.6-1 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11422 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
1.1-2 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11423 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
2.1-3 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 747 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11424 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
3.1-4 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11426 EXC H-F-NK-SP B9+MARG No* *PA req'd if performed as elective proc in
>4 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11440 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
0.5 CM/< the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11441 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
0.6-1 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11442 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
1.1-2 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11443 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
2.1-3 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11444 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
3.1-4 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

11446 EXC FACE-MM B9+MARG No* *PA req'd if performed as elective proc in
>4 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 748 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11450 REMOVAL SWEAT GLAND No

LESION

11451 REMOVAL SWEAT GLAND No

LESION

11462 REMOVAL SWEAT GLAND No

LESION

11463 REMOVAL SWEAT GLAND No

LESION

11470 REMOVAL SWEAT GLAND No

LESION

11471 REMOVAL SWEAT GLAND No

LESION

11600 EXC TR-EXT MAL+MARG No

0.5 CM/<

11601 EXC TR-EXT MAL+MARG No

0.6-1 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 749 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11602 EXC TR-EXT MAL+MARG No

1.1-2 CM

11603 EXC TR-EXT MAL+MARG No

2.1-3 CM

11604 EXC TR-EXT MAL+MARG No

3.1-4 CM

11606 EXC TR-EXT MAL+MARG No

>4 CM

11620 EXC H-F-NK-SP No

MAL+MARG 0.5/<

11621 EXC S/N/H/F/G No

MAL+MRG 0.6-1

11622 EXC S/N/H/F/G No

MAL+MRG 1.1-2

11623 EXC S/N/H/F/G No

MAL+MRG 2.1-3

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 750 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11624 EXC S/N/H/F/G No

MAL+MRG 3.1-4

11626 EXC S/N/H/F/G No

MAL+MRG >4 CM

11640 EXC F/E/E/N/L MAL+MRG No

0.5CM<

11641 EXC F/E/E/N/L MAL+MRG No

0.6-1

11642 EXC F/E/E/N/L MAL+MRG No

1.1-2

11643 EXC F/E/E/N/L MAL+MRG No

2.1-3

11644 EXC F/E/E/N/L MAL+MRG No

3.1-4

11646 EXC F/E/E/N/L MAL+MRG No

>4 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 751 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11719 TRIM NAIL(S) ANY No

NUMBER

11720 DEBRIDE NAIL 1-5 No

11721 DEBRIDE NAIL 6 OR MORE No

11730 REMOVAL OF NAIL PLATE No

11732 REMOVE NAIL PLATE No

ADD-ON

11740 DRAIN BLOOD FROM No

UNDER NAIL

11750 REMOVAL OF NAIL BED No

11752 REMOVE NAIL BED/TIP No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 752 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11755 BIOPSY NAIL UNIT No

11760 REPAIR OF NAIL BED No

11762 RECONSTRUCTION OF No
NAIL BED

11765 EXCISION OF NAIL FOLD No

TOE

11770 REMOVE PILONIDAL CYST No

SIMPLE

11771 REMOVE PILONIDAL CYST No

EXTEN

11772 REMOVE PILONIDAL CYST No

COMPL

11900 INJECT SKIN LESIONS </W No

7

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 753 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11901 INJECT SKIN LESIONS >7 No

11920 CORRECT SKIN COLOR 6.0 Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
CM/< more details (Effective 06/01/18)
Reconstruction

11921 CORRECT SKN COLOR 6.1- Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
20.0CM more details (Effective 06/01/18)
Reconstruction

11922 CORRECT SKIN COLOR EA No

20.0CM

11950 TX CONTOUR DEFECTS 1 Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
CC/< more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11951 TX CONTOUR DEFECTS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
1.1-5.0CC more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11952 TX CONTOUR DEFECTS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
5.1-10CC more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11954 TX CONTOUR DEFECTS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
>10.0 CC more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 754 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

11960 INSERT TISSUE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
EXPANDER(S) more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

11970 REPLACE TISSUE Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
EXPANDER more details (Effective 06/01/18)
Reconstruction

11971 REMOVE TISSUE Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
EXPANDER(S) *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

11976 REMOVE No
CONTRACEPTIVE CAPSULE

11980 IMPLANT HORMONE No

PELLET(S)

11981 INSERT DRUG IMPLANT No

DEVICE

11982 REMOVE DRUG IMPLANT No

DEVICE

11983 REMOVE/INSERT DRUG No

IMPLANT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 755 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

12001 RPR S/N/AX/GEN/TRNK No

2.5CM/<

12002 RPR No
S/N/AX/GEN/TRNK2.6-
7.5CM

12004 RPR S/N/AX/GEN/TRK7.6- No

12.5CM

12005 RPR S/N/A/GEN/TRK12.6- No

20.0CM

12006 RPR S/N/A/GEN/TRK20.1- No

30.0CM

12007 RPR S/N/AX/GEN/TRNK No

>30.0 CM

12011 RPR F/E/E/N/L/M 2.5 No

CM/<

12013 RPR F/E/E/N/L/M 2.6-5.0 No

CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 756 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

12014 RPR F/E/E/N/L/M 5.1-7.5 No

CM

12015 RPR F/E/E/N/L/M 7.6- No

12.5 CM

12016 RPR FE/E/EN/L/M 12.6- No

20.0 CM

12017 RPR FE/E/EN/L/M 20.1- No

30.0 CM

12018 RPR F/E/E/N/L/M >30.0 No

CM

12020 CLOSURE OF SPLIT No

WOUND

12021 CLOSURE OF SPLIT No

WOUND

12031 INTMD RPR S/A/T/EXT No

2.5 CM/<

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 757 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

12032 INTMD RPR S/A/T/EXT No

2.6-7.5

12034 INTMD RPR S/TR/EXT 7.6- No

12.5

12035 INTMD RPR S/A/T/EXT No

12.6-20

12036 INTMD RPR S/A/T/EXT No

20.1-30

12037 INTMD RPR S/TR/EXT No

>30.0 CM

12041 INTMD RPR N-HF/GENIT No

2.5CM/<

12042 INTMD RPR N- No

HF/GENIT2.6-7.5

12044 INTMD RPR N- No

HF/GENIT7.6-12.5

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 758 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

12045 INTMD RPR N- No

HF/GENIT12.6-20

12046 INTMD RPR N- No

HF/GENIT20.1-30

12047 INTMD RPR N-HF/GENIT No

>30.0CM

12051 INTMD RPR FACE/MM No

2.5 CM/<

12052 INTMD RPR FACE/MM No

2.6-5.0 CM

12053 INTMD RPR FACE/MM No

5.1-7.5 CM

12054 INTMD RPR FACE/MM No

7.6-12.5CM

12055 INTMD RPR FACE/MM No

12.6-20 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 759 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

12056 INTMD RPR FACE/MM No

20.1-30.0

12057 INTMD RPR FACE/MM No

>30.0 CM

13100 CMPLX RPR TRUNK 1.1- No* *PA req'd if performed as elective proc in
2.5 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13101 CMPLX RPR TRUNK 2.6- No* *PA req'd if performed as elective proc in
7.5 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13102 CMPLX RPR TRUNK ADDL No

5CM/<

13120 CMPLX RPR S/A/L 1.1-2.5 No* *PA req'd if performed as elective proc in
CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13121 CMPLX RPR S/A/L 2.6-7.5 No* *PA req'd if performed as elective proc in
CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13122 CMPLX RPR S/A/L ADDL 5 No

CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 760 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

13131 CMPLX RPR No* *PA req'd if performed as elective proc in

F/C/C/M/N/AX/G/H/F the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13132 CMPLX RPR No* *PA req'd if performed as elective proc in

F/C/C/M/N/AX/G/H/F the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13133 CMPLX RPR No

F/C/C/M/N/AX/G/H/F

13151 CMPLX RPR E/N/E/L 1.1- No* *PA req'd if performed as elective proc in
2.5 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13152 CMPLX RPR E/N/E/L 2.6- No* *PA req'd if performed as elective proc in
7.5 CM the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

13153 CMPLX RPR E/N/E/L No

ADDL 5CM/<

13160 LATE CLOSURE OF No

WOUND

14000 TIS TRNFR TRUNK 10 SQ No

CM/<

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 761 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

14001 TIS TRNFR TRUNK 10.1- No

30SQCM

14020 TIS TRNFR S/A/L 10 SQ No

CM/<

14021 TIS TRNFR S/A/L 10.1-30 No

SQCM

14040 TIS TRNFR No

F/C/C/M/N/A/G/H/F

14041 TIS TRNFR No

F/C/C/M/N/A/G/H/F

14060 TIS TRNFR E/N/E/L 10 SQ Yes* InterQual® criteria used. *Will be covered
IQ -
CM/< only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

14061 TIS TRNFR E/N/E/L10.1- Yes* InterQual® criteria used. *Will be covered
IQ -
30SQCM only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

14301 TIS TRNFR ANY 30.1-60 No

SQ CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 762 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

14302 TIS TRNFR ADDL 30 SQ No

CM/<

14350 FILLETED FINGER/TOE No

FLAP

15002 WOUND PREP No* *PA req'd if performed as elective proc in

TRK/ARM/LEG the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15003 WOUND PREP ADDL 100 No

CM

15004 WOUND PREP F/N/HF/G No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15005 WND PREP F/N/HF/G No

ADDL CM

15040 HARVEST CULTURED SKIN No

GRAFT

15050 SKIN PINCH GRAFT Yes* InterQual® criteria used. *Will be covered
IQ -
only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 763 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15100 SKIN SPLT GRFT Yes* InterQual® criteria used. *Will be covered
IQ -
TRNK/ARM/LEG only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15101 SKIN SPLT GRFT T/A/L No

ADD-ON

15110 EPIDRM AUTOGRFT Yes* InterQual® criteria used. *Will be covered

IQ -
TRNK/ARM/LEG only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15111 EPIDRM AUTOGRFT T/A/L No

ADD-ON

15115 EPIDRM A-GRFT Yes* InterQual® criteria used. *Will be covered

IQ -
FACE/NCK/HF/G only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15116 EPIDRM A-GRFT No

F/N/HF/G ADDL

15120 SKN SPLT A-GRFT Yes* InterQual® criteria used. *Will be covered
IQ -
FAC/NCK/HF/G only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15121 SKN SPLT A-GRFT No

F/N/HF/G ADD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 764 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15130 DERM AUTOGRAFT Yes* InterQual® criteria used. *Will be covered

IQ -
TRNK/ARM/LEG only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15131 DERM AUTOGRAFT T/A/L No

ADD-ON

15135 DERM AUTOGRAFT Yes* InterQual® criteria used. *Will be covered

IQ -
FACE/NCK/HF/G only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15136 DERM AUTOGRAFT No

F/N/HF/G ADD

15150 CULT SKIN GRFT Yes* InterQual® criteria used. *Will be covered
IQ -
T/ARM/LEG only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15151 CULT SKIN GRFT T/A/L No

ADDL

15152 CULT SKIN GRAFT T/A/L No

+%

15155 CULT SKIN GRAFT Yes* InterQual® criteria used. *Will be covered
IQ -
F/N/HF/G only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 765 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15156 CULT SKIN GRFT F/N/HFG No

ADD

15157 CULT EPIDERM GRFT No

F/N/HFG +%

15200 SKIN FULL GRAFT TRUNK Yes* InterQual® criteria used. *Will be covered
IQ -
only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15201 SKIN FULL GRAFT TRUNK No

ADD-ON

15220 SKIN FULL GRAFT Yes* InterQual® criteria used. *Will be covered
IQ -
SCLP/ARM/LEG only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15221 SKIN FULL GRAFT ADD-ON No

15240 SKIN FULL GRFT Yes* InterQual® criteria used. *Will be covered
IQ -
FACE/GENIT/HF only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15241 SKIN FULL GRAFT ADD-ON No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 766 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15260 SKIN FULL GRAFT EEN & Yes* InterQual® criteria used. *Will be covered
IQ -
LIPS only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15261 SKIN FULL GRAFT ADD-ON No

15271 SKIN SUB GRAFT No* *PA req'd if performed as elective proc in
TRNK/ARM/LEG the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15272 SKIN SUB GRAFT T/A/L No

ADD-ON

15273 SKIN SUB GRFT No* *PA req'd if performed as elective proc in
T/ARM/LG CHILD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15274 SKN SUB GRFT T/A/L No

CHILD ADD

15275 SKIN SUB GRAFT No* *PA req'd if performed as elective proc in
FACE/NK/HF/G the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15276 SKIN SUB GRAFT No

F/N/HF/G ADDL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 767 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15277 SKN SUB GRFT F/N/HF/G No* *PA req'd if performed as elective proc in
CHILD the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

15278 SKN SUB GRFT F/N/HF/G No

CH ADD

15570 SKIN PEDICLE FLAP TRUNK No

15572 SKIN PEDICLE FLAP No

ARMS/LEGS

15574 PEDCLE No
FH/CH/CH/M/N/AX/G/H/
F

15576 PEDICLE Yes* InterQual® criteria used. *Will be covered

IQ -
E/N/E/L/NTRORAL only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15600 DELAY FLAP TRUNK No

15610 DELAY FLAP ARMS/LEGS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 768 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15620 DELAY FLAP No

F/C/C/N/AX/G/H/F

15630 DELAY FLAP Yes* InterQual® criteria used. *Will be covered

IQ -
EYE/NOS/EAR/LIP only when performed in the Outpatient
Potentially setting.
Cosmetic
Surgery

15650 TRANSFER SKIN PEDICLE No

FLAP

15731 FOREHEAD FLAP W/VASC Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ -
PEDICLE documentation supporting rationale for
Potentially request (e.g., notes, lab values, X-rays, etc.)
Cosmetic
Surgery

15732 MUSCLE-SKIN GRAFT No

HEAD/NECK

15734 MUSCLE-SKIN GRAFT No

TRUNK

15736 MUSCLE-SKIN GRAFT ARM No

15738 MUSCLE-SKIN GRAFT LEG No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 769 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15740 ISLAND PEDICLE FLAP No

GRAFT

15750 NEUROVASCULAR No
PEDICLE FLAP

15756 FREE MYO/SKIN FLAP Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
MICROVASC more details 11/01/18)
Potentially
Cosmetic
Surgery

15757 FREE SKIN FLAP Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
MICROVASC more details 11/01/18)
Potentially
Cosmetic
Surgery

15758 FREE FASCIAL FLAP Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
MICROVASC more details 11/01/18)
Potentially
Cosmetic
Surgery

15760 COMPOSITE SKIN GRAFT No

15770 DERMA-FAT-FASCIA No
GRAFT

15775 HAIR TRNSPL 1-15 No

PUNCH GRFTS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 770 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15776 HAIR TRNSPL >15 PUNCH No

GRAFTS

15777 ACELLULAR DERM Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
MATRIX IMPLT more details (Effective 06/01/18)
Reconstruction

15780 DERMABRASION TOTAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
FACE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15781 DERMABRASION Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
SEGMENTAL FACE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15782 DERMABRASION OTHER Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
THAN FACE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15783 DERMABRASION SUPRFL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ANY SITE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15786 ABRASION LESION SINGLE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15787 ABRASION LESIONS ADD- Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ON more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 771 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15788 CHEMICAL PEEL FACE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
EPIDERM more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15789 CHEMICAL PEEL FACE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
DERMAL more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15792 CHEMICAL PEEL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
NONFACIAL more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15793 CHEMICAL PEEL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
NONFACIAL more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15819 PLASTIC SURGERY NECK Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15820 REVISION OF LOWER Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
EYELID more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15821 REVISION OF LOWER Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
EYELID more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

15822 REVISION OF UPPER Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
EYELID *Will be covered only when performed in
Surgery the Outpatient setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 772 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15823 REVISION OF UPPER Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Eye
EYELID *Will be covered only when performed in
Surgery the Outpatient setting.

15824 REMOVAL OF FOREHEAD No

WRINKLES

15825 REMOVAL OF NECK No

WRINKLES

15826 REMOVAL OF BROW No

WRINKLES

15828 REMOVAL OF FACE No

WRINKLES

15829 REMOVAL OF SKIN No

WRINKLES

15830 EXC SKIN ABD Yes* Please review BMCHP criteria for details. Panniculectomy and Redundant Skin Panniculectomy and
NH-
*Will be covered only when performed in Surgery Redundant Skin Surgery ( Eff
Pannic&Redun the Outpatient setting. 02/01/19)
dant Skin Surg

15832 EXCISE EXCESSIVE SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
THIGH more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 773 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15833 EXCISE EXCESSIVE SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
LEG more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15834 EXCISE EXCESSIVE SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
HIP more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15835 EXCISE EXCESSIVE SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
BUTTCK more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15836 EXCISE EXCESSIVE SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
ARM more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15837 EXCISE EXCESS SKIN Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
ARM/HAND more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15838 EXCISE EXCESS SKIN FAT Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
PAD more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15839 EXCISE EXCESS SKIN & Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
TISSUE more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15840 NERVE PALSY FASCIAL Yes InterQual® criteria used. Provide clinical
IQ - Ligament
GRAFT documentation supporting rationale for
tendon nerve request (e.g., notes, lab values, X-rays, etc.)
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 774 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15841 NERVE PALSY MUSCLE Yes InterQual® criteria used. Provide clinical
IQ - Ligament
GRAFT documentation supporting rationale for
tendon nerve request (e.g., notes, lab values, X-rays, etc.)
Surgery

15842 NERVE PALSY Yes InterQual® criteria used. Provide clinical

IQ - Ligament
MICROSURG GRAFT documentation supporting rationale for
tendon nerve request (e.g., notes, lab values, X-rays, etc.)
Surgery

15845 SKIN AND MUSCLE Yes InterQual® criteria used. Provide clinical
IQ - Ligament
REPAIR FACE documentation supporting rationale for
tendon nerve request (e.g., notes, lab values, X-rays, etc.)
Surgery

15847 EXC SKIN ABD ADD-ON Yes Please review the Well Sense Policy for Panniculectomy and Redundant Skin Panniculectomy and
NH-
more details Surgery Redundant Skin Surgery ( Eff
Pannic&Redun 02/01/19)
dant Skin Surg

15850 REMOVE SUTURES SAME No

SURGEON

15851 REMOVE SUTURES DIFF No

SURGEON

15852 DRESSING CHANGE NOT No

FOR BURN

15860 TEST FOR BLOOD FLOW No

IN GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 775 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15876 SUCTION LIPECTOMY Yes Depending on service, criteria is provided Panniculectomy and Redundant Skin Panniculectomy and
IQ -
HEAD&NECK in the Well Sense Policy OR InterQual® - Surgery Redundant Skin Surgery ( Eff
Potentially Potentially Cosmetic 02/01/19)
Cosmetic
Surgery

15877 SUCTION LIPECTOMY Yes* Please review BMCHP criteria for details. Panniculectomy and Redundant Skin Panniculectomy and
IQ -
TRUNK *Will be covered only when performed in Surgery Redundant Skin Surgery ( Eff
Potentially the Outpatient setting. 02/01/19)
Cosmetic
Surgery

15878 SUCTION LIPECTOMY Yes Depending on service, criteria is provided Panniculectomy and Redundant Skin Panniculectomy and
IQ -
UPR EXTREM in the Well Sense Policy OR InterQual® - Surgery Redundant Skin Surgery ( Eff
Potentially Potentially Cosmetic 02/01/19)
Cosmetic
Surgery

15879 SUCTION LIPECTOMY Yes Depending on service, criteria is provided Panniculectomy and Redundant Skin Panniculectomy and
IQ -
LWR EXTREM in the Well Sense Policy OR InterQual® - Surgery Redundant Skin Surgery ( Eff
Potentially Potentially Cosmetic 02/01/19)
Cosmetic
Surgery

15920 REMOVAL OF TAIL BONE No

ULCER

15922 REMOVAL OF TAIL BONE No

ULCER

15931 REMOVE SACRUM No

PRESSURE SORE

15933 REMOVE SACRUM No

PRESSURE SORE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 776 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15934 REMOVE SACRUM No

PRESSURE SORE

15935 REMOVE SACRUM No

PRESSURE SORE

15936 REMOVE SACRUM No

PRESSURE SORE

15937 REMOVE SACRUM No

PRESSURE SORE

15940 REMOVE HIP PRESSURE No

SORE

15941 REMOVE HIP PRESSURE No

SORE

15944 REMOVE HIP PRESSURE No

SORE

15945 REMOVE HIP PRESSURE No

SORE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 777 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

15946 REMOVE HIP PRESSURE No

SORE

15950 REMOVE THIGH No

PRESSURE SORE

15951 REMOVE THIGH No

PRESSURE SORE

15952 REMOVE THIGH No

PRESSURE SORE

15953 REMOVE THIGH No

PRESSURE SORE

15956 REMOVE THIGH No

PRESSURE SORE

15958 REMOVE THIGH No

PRESSURE SORE

15999 REMOVAL OF PRESSURE No

SORE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 778 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

16000 INITIAL TREATMENT OF No

BURN(S)

16020 DRESS/DEBRID P-THICK No

BURN S

16025 DRESS/DEBRID P-THICK No

BURN M

16030 DRESS/DEBRID P-THICK No

BURN L

16035 INCISION OF BURN SCAB No

INITI

16036 ESCHAROTOMY ADDL No

INCISION

17000 DESTRUCT PREMALG No

LESION

17003 DESTRUCT PREMALG LES No

2-14

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 779 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

17004 DESTROY PREMAL No

LESIONS 15/>

17106 DESTRUCTION OF SKIN No

LESIONS

17107 DESTRUCTION OF SKIN No

LESIONS

17108 DESTRUCTION OF SKIN No

LESIONS

17110 DESTRUCT B9 LESION 1- No

14

17111 DESTRUCT LESION 15 OR No

MORE

17250 CHEMICAL CAUTERY No

TISSUE

17260 DESTRUCTION OF SKIN No

LESIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 780 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

17261 DESTRUCTION OF SKIN No

LESIONS

17262 DESTRUCTION OF SKIN No

LESIONS

17263 DESTRUCTION OF SKIN No

LESIONS

17264 DESTRUCTION OF SKIN No

LESIONS

17266 DESTRUCTION OF SKIN No

LESIONS

17270 DESTRUCTION OF SKIN No

LESIONS

17271 DESTRUCTION OF SKIN No

LESIONS

17272 DESTRUCTION OF SKIN No

LESIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 781 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

17273 DESTRUCTION OF SKIN No

LESIONS

17274 DESTRUCTION OF SKIN No

LESIONS

17276 DESTRUCTION OF SKIN No

LESIONS

17280 DESTRUCTION OF SKIN No

LESIONS

17281 DESTRUCTION OF SKIN No

LESIONS

17282 DESTRUCTION OF SKIN No

LESIONS

17283 DESTRUCTION OF SKIN No

LESIONS

17284 DESTRUCTION OF SKIN No

LESIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 782 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

17286 DESTRUCTION OF SKIN No

LESIONS

17311 MOHS 1 STAGE H/N/HF/G No

17312 MOHS ADDL STAGE No

17313 MOHS 1 STAGE T/A/L No

17314 MOHS ADDL STAGE T/A/L No

17315 MOHS SURG ADDL BLOCK No

17340 CRYOTHERAPY OF SKIN No

17360 SKIN PEEL THERAPY Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 783 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

17380 HAIR REMOVAL BY Yes This policy applies to this code when billed
ELECTROLYSIS with DX code(s) F64.1-F64.9 and/or
Z87.890

17999 SKIN TISSUE PROCEDURE Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

19000 DRAINAGE OF BREAST No

LESION

19001 DRAIN BREAST LESION No

ADD-ON

19020 INCISION OF BREAST No

LESION

19030 INJECTION FOR BREAST X- No

RAY

19081 BX BREAST 1ST LESION No

STRTCTC

19082 BX BREAST ADD LESION No

STRTCTC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 784 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19083 BX BREAST 1ST LESION No

US IMAG

19084 BX BREAST ADD LESION No

US IMAG

19085 BX BREAST 1ST LESION No

MR IMAG

19086 BX BREAST ADD LESION No

MR IMAG

19100 BX BREAST PERCUT W/O No* *PA req'd if performed as elective proc in
IMAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

19101 BIOPSY OF BREAST OPEN No

19105 CRYOSURG ABLATE FA No

EACH

19110 NIPPLE EXPLORATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 785 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19112 EXCISE BREAST DUCT No

FISTULA

19120 REMOVAL OF BREAST No

LESION

19125 EXCISION BREAST LESION No

19126 EXCISION ADDL BREAST No

LESION

19260 REMOVAL OF CHEST No

WALL LESION

19271 REVISION OF CHEST WALL No

19272 EXTENSIVE CHEST WALL No

SURGERY

19281 PERQ DEVICE BREAST 1ST No

IMAG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 786 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19282 PERQ DEVICE BREAST EA No

IMAG

19283 PERQ DEV BREAST 1ST No

STRTCTC

19284 PERQ DEV BREAST ADD No

STRTCTC

19285 PERQ DEV BREAST 1ST US No

IMAG

19286 PERQ DEV BREAST ADD No

US IMAG

19287 PERQ DEV BREAST 1ST No

MR GUIDE

19288 PERQ DEV BREAST ADD No

MR GUIDE

19296 PLACE PO BREAST CATH No

FOR RAD

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 787 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19297 PLACE BREAST CATH FOR No

RAD

19298 PLACE BREAST RAD No

TUBE/CATHS

19300 REMOVAL OF BREAST Yes* Please review BMCHP criteria for details. Gynecomastia Surgery Gynecomastia Surgery (Eff
NH-
TISSUE *Will be covered only when performed in 06/01/18)
Gynecomastia the Outpatient setting.
Surg

19301 PARTIAL MASTECTOMY Yes This policy applies to this code when billed
IQ- GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

19302 P-MASTECTOMY W/LN No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

19303 MAST SIMPLE COMPLETE Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

19304 MAST SUBQ Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

19305 MAST RADICAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 788 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19306 MAST RAD URBAN TYPE No

19307 MAST MOD RAD No

19316 SUSPENSION OF BREAST Yes Please review the Well Sense Policy for Mastopexy Mastopexy (Eff 06/01/18)
NH-Mastopexy
more details

19318 REDUCTION OF LARGE Yes* Please review BMCHP criteria for details. Breast Reduction Mammoplasty Breast Reduction
NH-Breast
BREAST *Will be covered only when performed in Mammoplasty (Eff 06/01/18)
Reduction the Outpatient setting.
Mammoplasty

19324 ENLARGE BREAST Yes This policy applies to this code when billed
IQ - GYN
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

19325 ENLARGE BREAST WITH Yes This policy applies to this code when billed
IQ - GYN
IMPLANT with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

19328 REMOVAL OF BREAST Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
IMPLANT *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

19330 REMOVAL OF IMPLANT Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
MATERIAL *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 789 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19340 IMMEDIATE BREAST Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
PROSTHESIS *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

19342 DELAYED BREAST Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
PROSTHESIS *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

19350 BREAST Yes This policy applies to this code when billed Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION with DX code(s) F64.1-F64.9 and/or (Effective 06/01/18)
Reconstruction Z87.890

19355 CORRECT INVERTED Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
NIPPLE(S) more details (Effective 06/01/18)
Reconstruction

19357 BREAST Yes* Please review BMCHP criteria for details. Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION *Will be covered only when performed in (Effective 06/01/18)
Reconstruction the Outpatient setting.

19361 BREAST RECONSTR Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
W/LAT FLAP more details (Effective 06/01/18)
Reconstruction

19364 BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

19366 BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 790 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

19367 BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

19368 BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

19369 BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

19370 SURGERY OF BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
CAPSULE more details (Effective 06/01/18)
Reconstruction

19371 REMOVAL OF BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
CAPSULE more details (Effective 06/01/18)
Reconstruction

19380 REVISE BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
RECONSTRUCTION more details (Effective 06/01/18)
Reconstruction

19396 DESIGN CUSTOM BREAST Yes Please review the Well Sense Policy for Breast Reconstruction Breast Reconstruction
NH-Breast
IMPLANT more details (Effective 06/01/18)
Reconstruction

19499 BREAST SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 791 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

male genital system

54000 SLITTING OF PREPUCE No

54001 SLITTING OF PREPUCE No

54015 DRAIN PENIS LESION No

54050 DESTRUCTION PENIS No

LESION(S)

54055 DESTRUCTION PENIS No

LESION(S)

54056 CRYOSURGERY PENIS No

LESION(S)

54057 LASER SURG PENIS No

LESION(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 792 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54060 EXCISION OF PENIS No

LESION(S)

54065 DESTRUCTION PENIS No

LESION(S)

54100 BIOPSY OF PENIS No

54105 BIOPSY OF PENIS No

54110 TREATMENT OF PENIS No

LESION

54111 TREAT PENIS LESION No

GRAFT

54112 TREAT PENIS LESION No

GRAFT

54115 TREATMENT OF PENIS No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 793 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54120 PARTIAL REMOVAL OF Yes This policy applies to this code when billed
IQ - GU
PENIS with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

54125 REMOVAL OF PENIS Yes This policy applies to this code when billed
IQ - GU
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

54130 REMOVE PENIS & NODES No

54135 REMOVE PENIS & NODES No

54150 CIRCUMCISION Yes* *NOTE: This code does NOT require PA for
IQ - GU
W/REGIONL BLOCK ages 0-2 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

54160 CIRCUMCISION NEONATE No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54161 CIRCUM 28 DAYS OR Yes* *NOTE: This code does NOT require PA for
IQ - GU
OLDER ages 0-2 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

54162 LYSIS PENIL CIRCUMIC No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 794 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54163 REPAIR OF CIRCUMCISION No

54164 FRENULOTOMY OF PENIS No

54200 TREATMENT OF PENIS No

LESION

54205 TREATMENT OF PENIS No

LESION

54220 TREATMENT OF PENIS No

LESION

54230 PREPARE PENIS STUDY No

54231 DYNAMIC No
CAVERNOSOMETRY

54235 PENILE INJECTION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 795 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54240 PENIS STUDY No

54250 PENIS STUDY No

54300 REVISION OF PENIS No

54304 REVISION OF PENIS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54308 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54312 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54316 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54318 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 796 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54322 RECONSTRUCTION OF No
URETHRA

54324 RECONSTRUCTION OF No
URETHRA

54326 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54328 REVISE PENIS/URETHRA No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54332 REVISE PENIS/URETHRA No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54336 REVISE PENIS/URETHRA No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54340 SECONDARY URETHRAL No

SURGERY

54344 SECONDARY URETHRAL No* *PA req'd if performed as elective proc in

SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 797 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54348 SECONDARY URETHRAL No

SURGERY

54352 RECONSTRUCT No* *PA req'd if performed as elective proc in

URETHRA/PENIS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54360 PENIS PLASTIC SURGERY No

54380 REPAIR PENIS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54385 REPAIR PENIS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54390 REPAIR PENIS AND No* *PA req'd if performed as elective proc in
BLADDER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54400 INSERT SEMI-RIGID Yes This policy applies to this code when billed
PROSTHESIS with DX code(s) F64.1-F64.9 and/or
Z87.890

54401 INSERT SELF-CONTD Yes This policy applies to this code when billed
PROSTHESIS with DX code(s) F64.1-F64.9 and/or
Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 798 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54405 INSERT MULTI-COMP Yes This policy applies to this code when billed
PENIS PROS with DX code(s) F64.1-F64.9 and/or
Z87.890

54406 REMOVE MUTI-COMP No

PENIS PROS

54408 REPAIR MULTI-COMP No

PENIS PROS

54410 REMOVE/REPLACE PENIS No

PROSTH

54411 REMOV/REPLC PENIS No

PROS COMP

54415 REMOVE SELF-CONTD No

PENIS PROS

54416 REMV/REPL PENIS No

CONTAIN PROS

54417 REMV/REPLC PENIS PROS No

COMPL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 799 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54420 REVISION OF PENIS No

54430 REVISION OF PENIS No

54435 REVISION OF PENIS No

54437 REPAIR CORPOREAL TEAR No

54438 REPLANTATION OF PENIS No

54440 REPAIR OF PENIS No

54450 PREPUTIAL STRETCHING No

54500 BIOPSY OF TESTIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 800 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54505 BIOPSY OF TESTIS No

54512 EXCISE LESION TESTIS No

54520 REMOVAL OF TESTIS Yes This policy applies to this code when billed
IQ - GU
with DX code(s) F64.1-F64.9 and/or
Surgery Z87.890

54522 ORCHIECTOMY PARTIAL Yes* *NOTE: This code does NOT require PA for
IQ - GU
ages 0-18 yrs. Otherwise, Medically
Surgery Necessary criteria used. Provide clinical
documentation supporting rationale for
request.
54530 REMOVAL OF TESTIS No

54535 EXTENSIVE TESTIS No

SURGERY

54550 EXPLORATION FOR TESTIS No

54560 EXPLORATION FOR TESTIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 801 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54600 REDUCE TESTIS TORSION No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54620 SUSPENSION OF TESTIS No

54640 SUSPENSION OF TESTIS No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54650 ORCHIOPEXY (FOWLER- No* *PA req'd if performed as elective proc in

STEPHENS) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

54660 REVISION OF TESTIS Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

54670 REPAIR TESTIS INJURY No

54680 RELOCATION OF No
TESTIS(ES)

54690 LAPAROSCOPY Yes This policy applies to this code when billed
ORCHIECTOMY with DX code(s) F64.1-F64.9 and/or
Z87.890

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 802 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54692 LAPAROSCOPY No
ORCHIOPEXY

54699 LAPAROSCOPE PROC No

TESTIS

54700 DRAINAGE OF SCROTUM No

54800 BIOPSY OF EPIDIDYMIS No

54830 REMOVE EPIDIDYMIS No

LESION

54840 REMOVE EPIDIDYMIS No

LESION

54860 REMOVAL OF EPIDIDYMIS No

54861 REMOVAL OF EPIDIDYMIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 803 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

54865 EXPLORE EPIDIDYMIS No

54900 FUSION OF SPERMATIC No

DUCTS

54901 FUSION OF SPERMATIC No

DUCTS

55000 DRAINAGE OF No
HYDROCELE

55040 REMOVAL OF HYDROCELE Yes *NOTE: This code does NOT require PA for
IQ - GU
ages 0-18 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

55041 REMOVAL OF Yes* *NOTE: This code does NOT require PA for
IQ - GU
HYDROCELES ages 0-18 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

55060 REPAIR OF HYDROCELE Yes* *NOTE: This code does NOT require PA for
IQ - GU
ages 0-18 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

55100 DRAINAGE OF SCROTUM No

ABSCESS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 804 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55110 EXPLORE SCROTUM No

55120 REMOVAL OF SCROTUM No

LESION

55150 REMOVAL OF SCROTUM No

55175 REVISION OF SCROTUM Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

55180 REVISION OF SCROTUM Yes This policy applies to this code when billed
with DX code(s) F64.1-F64.9 and/or
Z87.890

55200 INCISION OF SPERM DUCT No

55250 REMOVAL OF SPERM No

DUCT(S)

55300 PREPARE SPERM DUCT X- No

RAY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 805 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55400 REPAIR OF SPERM DUCT No

55450 LIGATION OF SPERM No

DUCT

55500 REMOVAL OF HYDROCELE Yes* *NOTE: This code does NOT require PA for
IQ - GU
ages 0-18 yrs. Otherwise, InterQual®
Surgery criteria used. Will be covered only when
performed in the Outpatient setting.

55520 REMOVAL OF SPERM No

CORD LESION

55530 REVISE SPERMATIC CORD No

VEINS

55535 REVISE SPERMATIC CORD No

VEINS

55540 REVISE HERNIA & SPERM No

VEINS

55550 LAPARO LIGATE No

SPERMATIC VEIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 806 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55559 LAPARO PROC No

SPERMATIC CORD

55600 INCISE SPERM DUCT No

POUCH

55605 INCISE SPERM DUCT No

POUCH

55650 REMOVE SPERM DUCT No

POUCH

55680 REMOVE SPERM POUCH No

LESION

55700 BIOPSY OF PROSTATE No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

55705 BIOPSY OF PROSTATE No

55706 PROSTATE SATURATION No

SAMPLING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 807 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55720 DRAINAGE OF PROSTATE No

ABSCESS

55725 DRAINAGE OF PROSTATE No

ABSCESS

55801 REMOVAL OF PROSTATE No

55810 EXTENSIVE PROSTATE No

SURGERY

55812 EXTENSIVE PROSTATE No

SURGERY

55815 EXTENSIVE PROSTATE No

SURGERY

55821 REMOVAL OF PROSTATE No

55831 REMOVAL OF PROSTATE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 808 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55840 EXTENSIVE PROSTATE No

SURGERY

55842 EXTENSIVE PROSTATE No

SURGERY

55845 EXTENSIVE PROSTATE No

SURGERY

55860 SURGICAL EXPOSURE No

PROSTATE

55862 EXTENSIVE PROSTATE No

SURGERY

55865 EXTENSIVE PROSTATE No

SURGERY

55866 LAPARO RADICAL No

PROSTATECTOMY

55870 ELECTROEJACULATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 809 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

55873 CRYOABLATE PROSTATE No

55875 TRANSPERI NEEDLE No* *PA req'd if performed as elective proc in

PLACE PROS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

55876 PLACE RT No* *PA req'd if performed as elective proc in

DEVICE/MARKER PROS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

55899 GENITAL SURGERY No

PROCEDURE

maternity care and delivery

59000 AMNIOCENTESIS No
DIAGNOSTIC

59001 AMNIOCENTESIS No
THERAPEUTIC

59012 FETAL CORD PUNCTURE No

PRENATAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 810 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59015 CHORION BIOPSY No

59020 FETAL CONTRACT STRESS No

TEST

59025 FETAL NON-STRESS TEST No

59030 FETAL SCALP BLOOD No

SAMPLE

59050 FETAL MONITOR No

W/REPORT

59051 FETAL No
MONITOR/INTERPRET
ONLY

59070 TRANSABDOM No
AMNIOINFUS W/US

59072 UMBILICAL CORD No

OCCLUD W/US

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 811 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59074 FETAL FLUID DRAINAGE No

W/US

59076 FETAL SHUNT No

PLACEMENT W/US

59100 REMOVE UTERUS LESION No

59120 TREAT ECTOPIC No

PREGNANCY

59121 TREAT ECTOPIC No

PREGNANCY

59130 TREAT ECTOPIC No

PREGNANCY

59135 TREAT ECTOPIC No

PREGNANCY

59136 TREAT ECTOPIC No

PREGNANCY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 812 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59140 TREAT ECTOPIC No

PREGNANCY

59150 TREAT ECTOPIC No

PREGNANCY

59151 TREAT ECTOPIC No

PREGNANCY

59160 D & C AFTER DELIVERY No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59200 INSERT CERVICAL No

DILATOR

59300 EPISIOTOMY OR VAGINAL No

REPAIR

59320 REVISION OF CERVIX No

59325 REVISION OF CERVIX No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 813 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59350 REPAIR OF UTERUS No

59400 OBSTETRICAL CARE No

59409 OBSTETRICAL CARE No

59410 OBSTETRICAL CARE No

59412 ANTEPARTUM No
MANIPULATION

59414 DELIVER PLACENTA No

59425 ANTEPARTUM CARE ONLY No

59426 ANTEPARTUM CARE ONLY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 814 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59430 CARE AFTER DELIVERY No

59510 CESAREAN DELIVERY No

59514 CESAREAN DELIVERY No

ONLY

59515 CESAREAN DELIVERY No

59525 REMOVE UTERUS AFTER No

CESAREAN

59610 VBAC DELIVERY No

59612 VBAC DELIVERY ONLY No

59614 VBAC CARE AFTER No

DELIVERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 815 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59618 ATTEMPTED VBAC No

DELIVERY

59620 ATTEMPTED VBAC No

DELIVERY ONLY

59622 ATTEMPTED VBAC AFTER No

CARE

59812 TREATMENT OF No* *PA req'd if performed as elective proc in

MISCARRIAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59820 CARE OF MISCARRIAGE No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59821 TREATMENT OF No* *PA req'd if performed as elective proc in

MISCARRIAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59830 TREAT UTERUS INFECTION No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59840 ABORTION No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 816 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59841 ABORTION No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59850 ABORTION No

59851 ABORTION No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59852 ABORTION No

59855 ABORTION No

59856 ABORTION No

59857 ABORTION No

59866 ABORTION (MPR) No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 817 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

59870 EVACUATE MOLE OF No* *PA req'd if performed as elective proc in

UTERUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

59871 REMOVE CERCLAGE No

SUTURE

59897 FETAL INVAS PX W/US No

59898 LAPARO PROC OB No

CARE/DELIVER

59899 MATERNITY CARE No

PROCEDURE

mediastinum and diaphragm

39000 EXPLORATION OF CHEST No

39010 EXPLORATION OF CHEST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 818 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

39200 RESECT MEDIASTINAL No

CYST

39220 RESECT MEDIASTINAL No

TUMOR

39401 MEDIASTINOSCPY No
W/MEDSTNL BX

39402 MEDIASTINOSCPY No
W/LMPH NOD BX

39499 CHEST PROCEDURE No

39501 REPAIR DIAPHRAGM No

LACERATION

39503 REPAIR OF DIAPHRAGM No

HERNIA

39540 REPAIR OF DIAPHRAGM No

HERNIA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 819 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

39541 REPAIR OF DIAPHRAGM No

HERNIA

39545 REVISION OF DIAPHRAGM No

39560 RESECT DIAPHRAGM No

SIMPLE

39561 RESECT DIAPHRAGM No

COMPLEX

39599 DIAPHRAGM SURGERY No

PROCEDURE

musculoskeletal system
20005 I&D ABSCESS SUBFASCIAL No

20100 EXPLORE WOUND NECK No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 820 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20101 EXPLORE WOUND CHEST No

20102 EXPLORE WOUND No

ABDOMEN

20103 EXPLORE WOUND No

EXTREMITY

20150 EXCISE EPIPHYSEAL BAR No

20200 MUSCLE BIOPSY No

20205 DEEP MUSCLE BIOPSY No

20206 NEEDLE BIOPSY MUSCLE No

20220 BONE BIOPSY No

TROCAR/NEEDLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 821 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20225 BONE BIOPSY No

TROCAR/NEEDLE

20240 BONE BIOPSY OPEN No

SUPERFICIAL

20245 BONE BIOPSY OPEN DEEP No

20250 OPEN BONE BIOPSY No

20251 OPEN BONE BIOPSY No

20500 INJECTION OF SINUS No

TRACT

20501 INJECT SINUS TRACT FOR No

X-RAY

20520 REMOVAL OF FOREIGN No

BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 822 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20525 REMOVAL OF FOREIGN No

BODY

20526 THER INJECTION CARP No

TUNNEL

20527 INJ DUPUYTREN CORD No

W/ENZYME

20550 INJ TENDON No

SHEATH/LIGAMENT

20551 INJ TENDON No

ORIGIN/INSERTION

20552 INJ TRIGGER POINT 1/2 No

MUSCL

20553 INJECT TRIGGER POINTS No

3/>

20555 PLACE NDL MUSC/TIS No

FOR RT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 823 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20600 DRAIN/INJ JOINT/BURSA No

W/O US

20604 DRAIN/INJ JOINT/BURSA No

W/US

20605 DRAIN/INJ JOINT/BURSA Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
W/O US Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

20606 DRAIN/INJ JOINT/BURSA No

W/US

20610 DRAIN/INJ JOINT/BURSA No

W/O US

20611 DRAIN/INJ JOINT/BURSA No

W/US

20612 ASPIRATE/INJ GANGLION No

CYST

20615 TREATMENT OF BONE No

CYST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 824 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20650 INSERT AND REMOVE No

BONE PIN

20660 APPLY REM FIXATION No

DEVICE

20661 APPLICATION OF HEAD No

BRACE

20662 APPLICATION OF PELVIS No

BRACE

20663 APPLICATION OF THIGH No

BRACE

20664 APPLICATION OF HALO No

20665 REMOVAL OF FIXATION No

DEVICE

20670 REMOVAL OF SUPPORT No

IMPLANT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 825 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20680 REMOVAL OF SUPPORT No

IMPLANT

20690 APPLY BONE FIXATION No

DEVICE

20692 APPLY BONE FIXATION No

DEVICE

20693 ADJUST BONE FIXATION No

DEVICE

20694 REMOVE BONE FIXATION No

DEVICE

20696 COMP MULTIPLANE EXT No

FIXATION

20697 COMP EXT FIXATE STRUT No

CHANGE

20802 REPLANTATION ARM No

COMPLETE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 826 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20805 REPLANT FOREARM No

COMPLETE

20808 REPLANTATION HAND No

COMPLETE

20816 REPLANTATION DIGIT No

COMPLETE

20822 REPLANTATION DIGIT No

COMPLETE

20824 REPLANTATION THUMB No

COMPLETE

20827 REPLANTATION THUMB No

COMPLETE

20838 REPLANTATION FOOT No

COMPLETE

20900 REMOVAL OF BONE FOR No

GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 827 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20902 REMOVAL OF BONE FOR No

GRAFT

20910 REMOVE CARTILAGE FOR No

GRAFT

20912 REMOVE CARTILAGE FOR No

GRAFT

20920 REMOVAL OF FASCIA FOR No

GRAFT

20922 REMOVAL OF FASCIA FOR No

GRAFT

20924 REMOVAL OF TENDON No

FOR GRAFT

20926 REMOVAL OF TISSUE FOR No

GRAFT

20930 SP BONE ALGRFT No

MORSEL ADD-ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 828 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20931 SP BONE ALGRFT STRUCT No

ADD-ON

20936 SP BONE AGRFT LOCAL No

ADD-ON

20937 SP BONE AGRFT MORSEL No

ADD-ON

20938 SP BONE AGRFT STRUCT No

ADD-ON

20950 FLUID PRESSURE MUSCLE No

20955 FIBULA BONE GRAFT No

MICROVASC

20956 ILIAC BONE GRAFT No

MICROVASC

20957 MT BONE GRAFT No

MICROVASC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 829 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20962 OTHER BONE GRAFT No

MICROVASC

20969 BONE/SKIN GRAFT No

MICROVASC

20970 BONE/SKIN GRAFT ILIAC No

CREST

20972 BONE/SKIN GRAFT No

METATARSAL

20973 BONE/SKIN GRAFT GREAT No

TOE

20974 ELECTRICAL BONE No

STIMULATION

20975 ELECTRICAL BONE Yes InterQual® criteria used. Provide clinical

IQ - Other
STIMULATION documentation supporting rationale for
Orthopedic request (e.g., notes, lab values, X-rays, etc.)
Surgery

20979 US BONE STIMULATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 830 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

20982 ABLATE BONE TUMOR(S) No

PERQ

20983 ABLATE BONE TUMOR(S) No

PERQ

20985 CPTR-ASST DIR MS PX Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
NH-
more details Restorative Services and Restorative Services (Eff
Experimental/I 07/01/18)
nvestigation

20999 MUSCULOSKELETAL No
SURGERY

21010 INCISION OF JAW JOINT Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

21011 EXC FACE LES SC <2 CM No

21012 EXC FACE LES SBQ 2 CM/> No

21013 EXC FACE TUM DEEP < 2 No

CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 831 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21014 EXC FACE TUM DEEP 2 No

CM/>

21015 RESECT FACE/SCALP TUM No

< 2 CM

21016 RESECT FACE/SCALP TUM No

2 CM/>

21025 EXCISION OF BONE No

LOWER JAW

21026 EXCISION OF FACIAL No

BONE(S)

21029 CONTOUR OF FACE BONE No

LESION

21030 EXCISE MAX/ZYGOMA B9 No

TUMOR

21031 REMOVE EXOSTOSIS No

MANDIBLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 832 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21032 REMOVE EXOSTOSIS No

MAXILLA

21034 EXCISE MAX/ZYGOMA No

MAL TUMOR

21040 EXCISE MANDIBLE LESION No

21044 REMOVAL OF JAW BONE No

LESION

21045 EXTENSIVE JAW SURGERY No

21046 REMOVE MANDIBLE CYST No

COMPLEX

21047 EXCISE LWR JAW CYST No

W/REPAIR

21048 REMOVE MAXILLA CYST No

COMPLEX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 833 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21049 EXCIS UPPR JAW CYST No

W/REPAIR

21050 REMOVAL OF JAW JOINT Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

21060 REMOVE JAW JOINT Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
CARTILAGE Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

21070 REMOVE CORONOID Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
PROCESS Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

21073 MNPJ OF TMJ W/ANESTH No

21076 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21077 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21079 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 834 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21080 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21081 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21082 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21083 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21084 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21085 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21086 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21087 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 835 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21088 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21089 PREPARE FACE/ORAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
PROSTHESIS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21100 MAXILLOFACIAL FIXATION No

21110 INTERDENTAL FIXATION No

21116 INJECTION JAW JOINT X- Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
NH-TMJ
RAY Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
Disorder more details 01/01/19)
Treatment

21120 RECONSTRUCTION OF Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
CHIN more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21121 RECONSTRUCTION OF No
CHIN

21122 RECONSTRUCTION OF No
CHIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 836 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21123 RECONSTRUCTION OF No
CHIN

21125 AUGMENTATION LOWER Yes InterQual® criteria used. Provide clinical

IQ - Oral
JAW BONE documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21127 AUGMENTATION LOWER Yes InterQual® criteria used. Provide clinical

IQ - Oral
JAW BONE documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21137 REDUCTION OF No
FOREHEAD

21138 REDUCTION OF No
FOREHEAD

21139 REDUCTION OF No
FOREHEAD

21141 LEFORT I-1 PIECE W/O Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

21142 LEFORT I-2 PIECE W/O Yes InterQual® criteria used. Provide clinical
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 837 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21143 LEFORT I-3/> PIECE W/O Yes InterQual® criteria used. Provide clinical
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

21145 LEFORT I-1 PIECE W/ Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

21146 LEFORT I-2 PIECE W/ Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

21147 LEFORT I-3/> PIECE W/ Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
NH-IQ - ENT
GRAFT documentation supporting rationale for
Surg request (e.g., notes, lab values, X-rays, etc.)

21150 LEFORT II ANTERIOR Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
INTRUSION more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21151 LEFORT II W/BONE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
GRAFTS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21154 LEFORT III W/O LEFORT I No

21155 LEFORT III W/ LEFORT I No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 838 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21159 LEFORT III W/FHDW/O No

LEFORT I

21160 LEFORT III W/FHD W/ No

LEFORT I

21172 RECONSTRUCT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ORBIT/FOREHEAD more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21175 RECONSTRUCT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ORBIT/FOREHEAD more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21179 RECONSTRUCT ENTIRE No

FOREHEAD

21180 RECONSTRUCT ENTIRE No

FOREHEAD

21181 CONTOUR CRANIAL BONE No

LESION

21182 RECONSTRUCT CRANIAL No

BONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 839 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21183 RECONSTRUCT CRANIAL No

BONE

21184 RECONSTRUCT CRANIAL No

BONE

21188 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

MIDFACE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

21193 RECONST LWR JAW W/O Yes InterQual® criteria used. Provide clinical
IQ - Oral
GRAFT documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21194 RECONST LWR JAW Yes InterQual® criteria used. Provide clinical
IQ - Oral
W/GRAFT documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21195 RECONST LWR JAW W/O Yes InterQual® criteria used. Provide clinical
IQ - Oral
FIXATION documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21196 RECONST LWR JAW Yes InterQual® criteria used. Provide clinical
IQ - Oral
W/FIXATION documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21198 RECONSTR LWR JAW Yes* InterQual® criteria used. *Will be covered
IQ - Oral
SEGMENT only when performed in the Outpatient
Maxillofacial setting.
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 840 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21199 RECONSTR LWR JAW Yes* InterQual® criteria used. *Will be covered
IQ - Oral
W/ADVANCE only when performed in the Outpatient
Maxillofacial setting.
Surgery

21206 RECONSTRUCT UPPER Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Oral
JAW BONE *Will be covered only when performed in
Maxillofacial the Outpatient setting.
Surgery

21208 AUGMENTATION OF Yes InterQual® criteria used. Provide clinical

IQ - Oral
FACIAL BONES documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21209 REDUCTION OF FACIAL No

BONES

21210 FACE BONE GRAFT Yes InterQual® criteria used. Provide clinical
IQ - Oral
documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21215 LOWER JAW BONE GRAFT Yes InterQual® criteria used. Provide clinical
IQ - Oral
documentation supporting rationale for
Maxillofacial request (e.g., notes, lab values, X-rays, etc.)
Surgery

21230 RIB CARTILAGE GRAFT No

21235 EAR CARTILAGE GRAFT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 841 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21240 RECONSTRUCTION OF Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
JAW JOINT Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21242 RECONSTRUCTION OF Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
JAW JOINT Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21243 RECONSTRUCTION OF Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
JAW JOINT Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21244 RECONSTRUCTION OF Yes Provide clinical documentation supporting Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ - Dental
LOWER JAW rationale for request (e.g., notes, lab Restorative Services and Restorative Services (Eff
Surgery values, X-rays, etc.) 07/01/18)

21245 RECONSTRUCTION OF Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ - Dental
JAW documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

21246 RECONSTRUCTION OF Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ - Dental
JAW documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

21247 RECONSTRUCT LOWER No

JAW BONE

21248 RECONSTRUCTION OF Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ -
JAW more details
Potentially
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 842 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21249 RECONSTRUCTION OF Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ -
JAW more details
Potentially
cosmetic

21255 RECONSTRUCT LOWER No

JAW BONE

21256 RECONSTRUCTION OF No
ORBIT

21260 REVISE EYE SOCKETS No

21261 REVISE EYE SOCKETS No

21263 REVISE EYE SOCKETS No

21267 REVISE EYE SOCKETS No

21268 REVISE EYE SOCKETS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 843 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21270 AUGMENTATION CHEEK Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
BONE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21275 REVISION ORBITOFACIAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
BONES more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21280 REVISION OF EYELID Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21282 REVISION OF EYELID Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21295 REVISION OF JAW Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
MUSCLE/BONE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21296 REVISION OF JAW Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
MUSCLE/BONE more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

21299 CRANIO/MAXILLOFACIAL Yes* InterQual® criteria used. *Will be covered

IQ - Oral
SURGERY only when performed in the Outpatient
Maxillofacial setting.
Surgery

21310 CLOSED TX NOSE FX W/O No

MANJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 844 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21315 CLOSED TX NOSE FX W/O No

STABLJ

21320 CLOSED TX NOSE FX W/ No

STABLJ

21325 OPEN TX NOSE FX No

UNCOMPLICATD

21330 OPEN TX NOSE FX No

W/SKELE FIXJ

21335 OPEN TX NOSE & SEPTAL No

FX

21336 OPEN TX SEPTAL FX No

W/WO STABJ

21337 CLOSED TX No
SEPTAL&NOSE FX

21338 OPEN NASOETHMOID FX No

W/O FIXJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 845 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21339 OPEN NASOETHMOID FX No

W/ FIXJ

21340 PERQ TX NASOETHMOID No

FX

21343 OPEN TX DPRSD FRONT No

SINUS FX

21344 OPEN TX COMPL FRONT No

SINUS FX

21345 CLOSED TX NOSE/JAW FX No

21346 OPN TX NASOMAX FX No

W/FIXJ

21347 OPN TX NASOMAX FX No

MULTPLE

21348 OPN TX NASOMAX FX No

W/GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 846 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21355 PERQ TX MALAR No

FRACTURE

21356 OPN TX DPRSD No

ZYGOMATIC ARCH

21360 OPN TX DPRSD MALAR No

FRACTURE

21365 OPN TX COMPLX MALAR No

FX

21366 OPN TX COMPLX MALAR No

W/GRFT

21385 OPN TX ORBIT FX No

TRANSANTRAL

21386 OPN TX ORBIT FX No

PERIORBITAL

21387 OPN TX ORBIT FX No

COMBINED

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 847 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21390 OPN TX ORBIT PERIORBTL No

IMPLT

21395 OPN TX ORBIT PERIORBT No

W/GRFT

21400 CLOSED TX ORBIT W/O No

MANIPULJ

21401 CLOSED TX ORBIT No

W/MANIPULJ

21406 OPN TX ORBIT FX W/O No

IMPLANT

21407 OPN TX ORBIT FX No

W/IMPLANT

21408 OPN TX ORBIT FX No

W/BONE GRFT

21421 TREAT MOUTH ROOF No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 848 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21422 TREAT MOUTH ROOF No

FRACTURE

21423 TREAT MOUTH ROOF No

FRACTURE

21431 TREAT CRANIOFACIAL No

FRACTURE

21432 TREAT CRANIOFACIAL No

FRACTURE

21433 TREAT CRANIOFACIAL No

FRACTURE

21435 TREAT CRANIOFACIAL No

FRACTURE

21436 TREAT CRANIOFACIAL No

FRACTURE

21440 TREAT DENTAL RIDGE No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 849 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21445 TREAT DENTAL RIDGE No

FRACTURE

21450 TREAT LOWER JAW No

FRACTURE

21451 TREAT LOWER JAW No

FRACTURE

21452 TREAT LOWER JAW No

FRACTURE

21453 TREAT LOWER JAW No

FRACTURE

21454 TREAT LOWER JAW No

FRACTURE

21461 TREAT LOWER JAW No

FRACTURE

21462 TREAT LOWER JAW No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 850 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21465 TREAT LOWER JAW No

FRACTURE

21470 TREAT LOWER JAW No

FRACTURE

21480 RESET DISLOCATED JAW Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21485 RESET DISLOCATED JAW Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21490 REPAIR DISLOCATED JAW Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

21495 TREAT HYOID BONE No

FRACTURE

21497 INTERDENTAL WIRING No

21499 HEAD SURGERY No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 851 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21501 DRAIN NECK/CHEST No

LESION

21502 DRAIN CHEST LESION No

21510 DRAINAGE OF BONE No

LESION

21550 BIOPSY OF NECK/CHEST No

21552 EXC NECK LES SC 3 CM/> No

21554 EXC NECK TUM DEEP 5 No

CM/>

21555 EXC NECK LES SC < 3 CM No

21556 EXC NECK TUM DEEP < 5 No

CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 852 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21557 RESECT NECK THORAX No

TUMOR<5CM

21558 RESECT NECK TUMOR 5 No

CM/>

21600 PARTIAL REMOVAL OF RIB No

21610 PARTIAL REMOVAL OF RIB No

21615 REMOVAL OF RIB No

21616 REMOVAL OF RIB AND No

NERVES

21620 PARTIAL REMOVAL OF No

STERNUM

21627 STERNAL DEBRIDEMENT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 853 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21630 EXTENSIVE STERNUM No

SURGERY

21632 EXTENSIVE STERNUM No

SURGERY

21685 HYOID MYOTOMY & No

SUSPENSION

21700 REVISION OF NECK No

MUSCLE

21705 REVISION OF NECK No

MUSCLE/RIB

21720 REVISION OF NECK No

MUSCLE

21725 REVISION OF NECK No

MUSCLE

21740 RECONSTRUCTION OF Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ -
STERNUM documentation supporting rationale for
Potentially request (e.g., notes, lab values, X-rays, etc.)
Cosmetic
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 854 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21742 REPAIR STERN/NUSS Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ -
W/O SCOPE documentation supporting rationale for
Potentially request (e.g., notes, lab values, X-rays, etc.)
Cosmetic
Surgery

21743 REPAIR STERNUM/NUSS Yes InterQual® criteria used. Provide clinical InterQual® criteria is available
IQ -
W/SCOPE documentation supporting rationale for
Potentially request (e.g., notes, lab values, X-rays, etc.)
Cosmetic
Surgery

21750 REPAIR OF STERNUM No

SEPARATION

21811 OPTX OF RIB FX W/FIXJ No

SCOPE

21812 TREATMENT OF RIB No

FRACTURE

21813 TREATMENT OF RIB No

FRACTURE

21820 TREAT STERNUM No

FRACTURE

21825 TREAT STERNUM No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 855 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21899 NECK/CHEST SURGERY No

PROCEDURE

21920 BIOPSY SOFT TISSUE OF No

BACK

21925 BIOPSY SOFT TISSUE OF No

BACK

21930 EXC BACK LES SC < 3 CM No

21931 EXC BACK LES SC 3 CM/> No

21932 EXC BACK TUM DEEP < 5 No

CM

21933 EXC BACK TUM DEEP 5 No

CM/>

21935 RESECT BACK TUM < 5 CM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 856 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

21936 RESECT BACK TUM 5 No

CM/>

22010 I&D P-SPINE C/T/CERV- No

THOR

22015 I&D ABSCESS P-SPINE No

L/S/LS

22100 REMOVE PART OF NECK No

VERTEBRA

22101 REMOVE PART THORAX No

VERTEBRA

22102 REMOVE PART LUMBAR No

VERTEBRA

22103 REMOVE EXTRA SPINE No

SEGMENT

22110 REMOVE PART OF NECK No

VERTEBRA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 857 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22112 REMOVE PART THORAX No

VERTEBRA

22114 REMOVE PART LUMBAR No

VERTEBRA

22116 REMOVE EXTRA SPINE No

SEGMENT

22206 INCIS SPINE 3 COLUMN Yes InterQual® criteria used. Provide clinical
IQ - Spine
THORAC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22207 INCIS SPINE 3 COLUMN Yes InterQual® criteria used. Provide clinical
IQ - Spine
LUMBAR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22208 INCIS SPINE 3 COLUMN No

ADL SEG

22210 INCIS 1 VERTEBRAL SEG No

CERV

22212 INCIS 1 VERTEBRAL SEG No

THORAC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 858 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22214 INCIS 1 VERTEBRAL SEG No

LUMBAR

22216 INCIS ADDL SPINE No

SEGMENT

22220 INCIS W/DISCECTOMY No

CERVICAL

22222 INCIS W/DISCECTOMY No

THORACIC

22224 INCIS W/DISCECTOMY No* *PA req'd if performed as elective proc in

LUMBAR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

22226 REVISE EXTRA SPINE No

SEGMENT

22305 CLOSED TX SPINE No

PROCESS FX

22310 CLOSED TX VERT FX W/O No

MANJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 859 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22315 CLOSED TX VERT FX No

W/MANJ

22318 TREAT ODONTOID FX No

W/O GRAFT

22319 TREAT ODONTOID FX No

W/GRAFT

22325 TREAT SPINE FRACTURE No

22326 TREAT NECK SPINE No

FRACTURE

22327 TREAT THORAX SPINE No

FRACTURE

22328 TREAT EACH ADD SPINE No

FX

22505 MANIPULATION OF SPINE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 860 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22510 PERQ CERVICOTHORACIC No

INJECT

22511 PERQ LUMBOSACRAL No

INJECTION

22512 VERTEBROPLASTY ADDL No

INJECT

22513 PERQ VERTEBRAL No

AUGMENTATION

22514 PERQ VERTEBRAL No

AUGMENTATION

22515 PERQ VERTEBRAL No

AUGMENTATION

22526 IDET SINGLE LEVEL Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
NH-Thermal
more details Back Pain Treatments for Back Pain (Eff
Intradiscal 03/01/18)
Surg

22527 IDET 1 OR MORE LEVELS Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
NH-Thermal
more details Back Pain Treatments for Back Pain (Eff
Intradiscal 03/01/18)
Surg

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 861 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22532 LAT THORAX SPINE Yes InterQual® criteria used. Provide clinical
IQ - Spine
FUSION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22533 LAT LUMBAR SPINE Yes InterQual® criteria used. Provide clinical
IQ - Spine
FUSION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22534 LAT THOR/LUMB ADDL No

SEG

22548 NECK SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22551 NECK SPINE Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ - Spine
FUSE&REMOV BEL C2 more details
Surgery

22552 ADDL NECK SPINE FUSION No InterQual® criteria is available

22554 NECK SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22556 THORAX SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 862 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22558 LUMBAR SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22585 ADDITIONAL SPINAL No

FUSION

22586 PRESCRL FUSE W/ INSTR No

L5-S1

22590 SPINE & SKULL SPINAL Yes InterQual® criteria used. Provide clinical
IQ - Spine
FUSION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22595 NECK SPINAL FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22600 NECK SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22610 THORAX SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22612 LUMBAR SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 863 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22614 SPINE FUSION EXTRA No

SEGMENT

22630 LUMBAR SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22632 SPINE FUSION EXTRA No

SEGMENT

22633 LUMBAR SPINE FUSION Yes InterQual® criteria used. Provide clinical
IQ - Spine
COMBINED documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

22634 SPINE FUSION EXTRA No

SEGMENT

22800 POST FUSION </6 VERT No

SEG

22802 POST FUSION 7-12 VERT No

SEG

22804 POST FUSION 13/> VERT No

SEG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 864 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22808 ANT FUSION 2-3 VERT SEG No

22810 ANT FUSION 4-7 VERT SEG No

22812 ANT FUSION 8/> VERT No

SEG

22818 KYPHECTOMY 1-2 No

SEGMENTS

22819 KYPHECTOMY 3 OR MORE No

22830 EXPLORATION OF SPINAL No

FUSION

22840 INSERT SPINE FIXATION No

DEVICE

22841 INSERT SPINE FIXATION No

DEVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 865 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22842 INSERT SPINE FIXATION No

DEVICE

22843 INSERT SPINE FIXATION No

DEVICE

22844 INSERT SPINE FIXATION No

DEVICE

22845 INSERT SPINE FIXATION No

DEVICE

22846 INSERT SPINE FIXATION No

DEVICE

22847 INSERT SPINE FIXATION No

DEVICE

22848 INSERT PELV FIXATION No

DEVICE

22849 REINSERT SPINAL No

FIXATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 866 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22850 REMOVE SPINE FIXATION No

DEVICE

22851 APPLY SPINE PROSTH No

DEVICE

22852 REMOVE SPINE FIXATION No

DEVICE

22855 REMOVE SPINE FIXATION No

DEVICE

22856 CERV ARTIFIC Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
DISKECTOMY more details Replacement (Eff 03/01/18)

22857 LUMBAR ARTIF No

DISKECTOMY

22858 SECOND LEVEL CER Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
DISKECTOMY more details Replacement (Eff 03/01/18)

22861 REVISE CERV ARTIFIC DISC Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
more details Replacement (Eff 03/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 867 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22862 REVISE LUMBAR ARTIF No

DISC

22864 REMOVE CERV ARTIF DISC Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
more details Replacement (Eff 03/01/18)

22865 REMOVE LUMB ARTIF No

DISC

22869 INSJ STABLJ DEV W/O Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
Spine Surgery
DCMPRN more details Back Pain Treatments for Back Pain (Eff
03/01/18)

22870 INSJ STABLJ DEV W/O Yes

Spine Surgery
DCMPRN

22899 SPINE SURGERY Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
Spine Surgery
PROCEDURE more details Back Pain Treatments for Back Pain (Eff
03/01/18)

22900 EXC ABDL TUM DEEP < 5 No

CM

22901 EXC ABDL TUM DEEP 5 No

CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 868 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

22902 EXC ABD LES SC < 3 CM No

22903 EXC ABD LES SC 3 CM/> No

22904 RADICAL RESECT ABD No

TUMOR<5CM

22905 RAD RESECT ABD TUMOR No

5 CM/>

22999 ABDOMEN SURGERY No

PROCEDURE

23000 REMOVAL OF CALCIUM No

DEPOSITS

23020 RELEASE SHOULDER No

JOINT

23030 DRAIN SHOULDER LESION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 869 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23031 DRAIN SHOULDER BURSA No

23035 DRAIN SHOULDER BONE No

LESION

23040 EXPLORATORY No
SHOULDER SURGERY

23044 EXPLORATORY No
SHOULDER SURGERY

23065 BIOPSY SHOULDER No

TISSUES

23066 BIOPSY SHOULDER No

TISSUES

23071 EXC SHOULDER LES SC 3 No

CM/>

23073 EXC SHOULDER TUM No

DEEP 5 CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 870 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23075 EXC SHOULDER LES SC < 3 No

CM

23076 EXC SHOULDER TUM No

DEEP < 5 CM

23077 RESECT SHOULDER No

TUMOR < 5 CM

23078 RESECT SHOULDER No

TUMOR 5 CM/>

23100 BIOPSY OF SHOULDER No

JOINT

23101 SHOULDER JOINT No

SURGERY

23105 REMOVE SHOULDER No

JOINT LINING

23106 INCISION OF No
COLLARBONE JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 871 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23107 EXPLORE TREAT No

SHOULDER JOINT

23120 PARTIAL REMOVAL No

COLLAR BONE

23125 REMOVAL OF COLLAR No

BONE

23130 REMOVE SHOULDER No* *PA req'd if performed as elective proc in

BONE PART the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23140 REMOVAL OF BONE No

LESION

23145 REMOVAL OF BONE No

LESION

23146 REMOVAL OF BONE No

LESION

23150 REMOVAL OF HUMERUS No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 872 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23155 REMOVAL OF HUMERUS No

LESION

23156 REMOVAL OF HUMERUS No

LESION

23170 REMOVE COLLAR BONE No

LESION

23172 REMOVE SHOULDER No

BLADE LESION

23174 REMOVE HUMERUS No

LESION

23180 REMOVE COLLAR BONE No

LESION

23182 REMOVE SHOULDER No

BLADE LESION

23184 REMOVE HUMERUS No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 873 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23190 PARTIAL REMOVAL OF No

SCAPULA

23195 REMOVAL OF HEAD OF No

HUMERUS

23200 RESECT CLAVICLE TUMOR No

23210 RESECT SCAPULA TUMOR No

23220 RESECT PROX HUMERUS No

TUMOR

23330 REMOVE SHOULDER No

FOREIGN BODY

23333 REMOVE SHOULDER FB No

DEEP

23334 SHOULDER PROSTHESIS No

REMOVAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 874 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23335 SHOULDER PROSTHESIS No

REMOVAL

23350 INJECTION FOR No

SHOULDER X-RAY

23395 MUSCLE TRANSFER No

SHOULDER/ARM

23397 MUSCLE TRANSFERS No

23400 FIXATION OF SHOULDER No

BLADE

23405 INCISION OF TENDON & No

MUSCLE

23406 INCISE TENDON(S) & No

MUSCLE(S)

23410 REPAIR ROTATOR CUFF No* *PA req'd if performed as elective proc in
ACUTE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 875 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23412 REPAIR ROTATOR CUFF No* *PA req'd if performed as elective proc in
CHRONIC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23415 RELEASE OF SHOULDER No* *PA req'd if performed as elective proc in

LIGAMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23420 REPAIR OF SHOULDER No

23430 REPAIR BICEPS TENDON No

23440 REMOVE/TRANSPLANT No
TENDON

23450 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23455 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23460 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 876 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23462 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23465 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23466 REPAIR SHOULDER No* *PA req'd if performed as elective proc in

CAPSULE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23470 RECONSTRUCT Yes InterQual® criteria used. Provide clinical

IQ - Shoulder
SHOULDER JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

23472 RECONSTRUCT Yes InterQual® criteria used. Provide clinical

IQ - Shoulder
SHOULDER JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

23473 REVIS RECONST No

SHOULDER JOINT

23474 REVIS RECONST No

SHOULDER JOINT

23480 REVISION OF COLLAR No

BONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 877 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23485 REVISION OF COLLAR No

BONE

23490 REINFORCE CLAVICLE No

23491 REINFORCE SHOULDER No

BONES

23500 TREAT CLAVICLE No

FRACTURE

23505 TREAT CLAVICLE No

FRACTURE

23515 TREAT CLAVICLE No

FRACTURE

23520 TREAT CLAVICLE No

DISLOCATION

23525 TREAT CLAVICLE No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 878 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23530 TREAT CLAVICLE No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23532 TREAT CLAVICLE No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23540 TREAT CLAVICLE No

DISLOCATION

23545 TREAT CLAVICLE No

DISLOCATION

23550 TREAT CLAVICLE No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23552 TREAT CLAVICLE No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23570 TREAT SHOULDER BLADE No

FX

23575 TREAT SHOULDER BLADE No

FX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 879 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23585 TREAT SCAPULA No* *PA req'd if performed as elective proc in

FRACTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

23600 TREAT HUMERUS No

FRACTURE

23605 TREAT HUMERUS No

FRACTURE

23615 TREAT HUMERUS No

FRACTURE

23616 TREAT HUMERUS No

FRACTURE

23620 TREAT HUMERUS No

FRACTURE

23625 TREAT HUMERUS No

FRACTURE

23630 TREAT HUMERUS No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 880 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23650 TREAT SHOULDER No

DISLOCATION

23655 TREAT SHOULDER No

DISLOCATION

23660 TREAT SHOULDER No

DISLOCATION

23665 TREAT No
DISLOCATION/FRACTURE

23670 TREAT No
DISLOCATION/FRACTURE

23675 TREAT No
DISLOCATION/FRACTURE

23680 TREAT No
DISLOCATION/FRACTURE

23700 FIXATION OF SHOULDER No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 881 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23800 FUSION OF SHOULDER No

JOINT

23802 FUSION OF SHOULDER No

JOINT

23900 AMPUTATION OF ARM & No

GIRDLE

23920 AMPUTATION AT No
SHOULDER JOINT

23921 AMPUTATION FOLLOW- No

UP SURGERY

23929 SHOULDER SURGERY No

PROCEDURE

23930 DRAINAGE OF ARM No

LESION

23931 DRAINAGE OF ARM No

BURSA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 882 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

23935 DRAIN ARM/ELBOW No

BONE LESION

24000 EXPLORATORY ELBOW No

SURGERY

24006 RELEASE ELBOW JOINT No

24065 BIOPSY ARM/ELBOW No

SOFT TISSUE

24066 BIOPSY ARM/ELBOW No

SOFT TISSUE

24071 EXC ARM/ELBOW LES SC No

3 CM/>

24073 EX ARM/ELBOW TUM No

DEEP 5 CM/>

24075 EXC ARM/ELBOW LES SC No

< 3 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 883 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24076 EX ARM/ELBOW TUM No

DEEP < 5 CM

24077 RESECT ARM/ELBOW No

TUM < 5 CM

24079 RESECT ARM/ELBOW No

TUM 5 CM/>

24100 BIOPSY ELBOW JOINT No

LINING

24101 EXPLORE/TREAT ELBOW No

JOINT

24102 REMOVE ELBOW JOINT No

LINING

24105 REMOVAL OF ELBOW No

BURSA

24110 REMOVE HUMERUS No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 884 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24115 REMOVE/GRAFT BONE No

LESION

24116 REMOVE/GRAFT BONE No

LESION

24120 REMOVE ELBOW LESION No

24125 REMOVE/GRAFT BONE No

LESION

24126 REMOVE/GRAFT BONE No

LESION

24130 REMOVAL OF HEAD OF No

RADIUS

24134 REMOVAL OF ARM BONE No

LESION

24136 REMOVE RADIUS BONE No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 885 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24138 REMOVE ELBOW BONE No

LESION

24140 PARTIAL REMOVAL OF No

ARM BONE

24145 PARTIAL REMOVAL OF No

RADIUS

24147 PARTIAL REMOVAL OF No

ELBOW

24149 RADICAL RESECTION OF No

ELBOW

24150 RESECT DISTAL No

HUMERUS TUMOR

24152 RESECT RADIUS TUMOR No

24155 REMOVAL OF ELBOW No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 886 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24160 REMOVE ELBOW JOINT No

IMPLANT

24164 REMOVE RADIUS HEAD No

IMPLANT

24200 REMOVAL OF ARM No

FOREIGN BODY

24201 REMOVAL OF ARM No

FOREIGN BODY

24220 INJECTION FOR ELBOW X- No

RAY

24300 MANIPULATE ELBOW No

W/ANESTH

24301 MUSCLE/TENDON No
TRANSFER

24305 ARM TENDON No

LENGTHENING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 887 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24310 REVISION OF ARM No

TENDON

24320 REPAIR OF ARM TENDON No

24330 REVISION OF ARM No

MUSCLES

24331 REVISION OF ARM No

MUSCLES

24332 TENOLYSIS TRICEPS No

24340 REPAIR OF BICEPS No

TENDON

24341 REPAIR ARM No

TENDON/MUSCLE

24342 REPAIR OF RUPTURED No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 888 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24343 REPR ELBOW LAT No

LIGMNT W/TISS

24344 RECONSTRUCT ELBOW No

LAT LIGMNT

24345 REPR ELBW MED LIGMNT No

W/TISSU

24346 RECONSTRUCT ELBOW No

MED LIGMNT

24357 REPAIR ELBOW PERC No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

24358 REPAIR ELBOW W/DEB No* *PA req'd if performed as elective proc in
OPEN the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

24359 REPAIR ELBOW No* *PA req'd if performed as elective proc in

DEB/ATTCH OPEN the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

24360 RECONSTRUCT ELBOW Yes InterQual® criteria used. Provide clinical

IQ - Elbow
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 889 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24361 RECONSTRUCT ELBOW Yes InterQual® criteria used. Provide clinical

IQ - Elbow
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

24362 RECONSTRUCT ELBOW Yes InterQual® criteria used. Provide clinical

IQ - Elbow
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

24363 REPLACE ELBOW JOINT Yes InterQual® criteria used. Provide clinical
IQ - Elbow
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

24365 RECONSTRUCT HEAD OF Yes Provide clinical documentation supporting

IQ - Elbow
RADIUS rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

24366 RECONSTRUCT HEAD OF No

RADIUS

24370 REVISE RECONST ELBOW No

JOINT

24371 REVISE RECONST ELBOW No

JOINT

24400 REVISION OF HUMERUS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 890 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24410 REVISION OF HUMERUS No

24420 REVISION OF HUMERUS No

24430 REPAIR OF HUMERUS No

24435 REPAIR HUMERUS WITH No

GRAFT

24470 REVISION OF ELBOW No

JOINT

24495 DECOMPRESSION OF No
FOREARM

24498 REINFORCE HUMERUS No

24500 TREAT HUMERUS No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 891 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24505 TREAT HUMERUS No

FRACTURE

24515 TREAT HUMERUS No

FRACTURE

24516 TREAT HUMERUS No

FRACTURE

24530 TREAT HUMERUS No

FRACTURE

24535 TREAT HUMERUS No

FRACTURE

24538 TREAT HUMERUS No

FRACTURE

24545 TREAT HUMERUS No

FRACTURE

24546 TREAT HUMERUS No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 892 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24560 TREAT HUMERUS No

FRACTURE

24565 TREAT HUMERUS No

FRACTURE

24566 TREAT HUMERUS No

FRACTURE

24575 TREAT HUMERUS No

FRACTURE

24576 TREAT HUMERUS No

FRACTURE

24577 TREAT HUMERUS No

FRACTURE

24579 TREAT HUMERUS No

FRACTURE

24582 TREAT HUMERUS No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 893 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24586 TREAT ELBOW FRACTURE No

24587 TREAT ELBOW FRACTURE No

24600 TREAT ELBOW No

DISLOCATION

24605 TREAT ELBOW No

DISLOCATION

24615 TREAT ELBOW No

DISLOCATION

24620 TREAT ELBOW FRACTURE No

24635 TREAT ELBOW FRACTURE No

24640 TREAT ELBOW No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 894 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24650 TREAT RADIUS FRACTURE No

24655 TREAT RADIUS FRACTURE No

24665 TREAT RADIUS FRACTURE No

24666 TREAT RADIUS FRACTURE No

24670 TREAT ULNAR FRACTURE No

24675 TREAT ULNAR FRACTURE No

24685 TREAT ULNAR FRACTURE No

24800 FUSION OF ELBOW JOINT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 895 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24802 FUSION/GRAFT OF No
ELBOW JOINT

24900 AMPUTATION OF UPPER No

ARM

24920 AMPUTATION OF UPPER No

ARM

24925 AMPUTATION FOLLOW- No

UP SURGERY

24930 AMPUTATION FOLLOW- No

UP SURGERY

24931 AMPUTATE UPPER ARM No

& IMPLANT

24935 REVISION OF No
AMPUTATION

24940 REVISION OF UPPER ARM No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 896 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

24999 UPPER ARM/ELBOW No

SURGERY

25000 INCISION OF TENDON Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ - Ligament
SHEATH more details 11/01/18)
tendon nerve
Surgery

25001 INCISE FLEXOR CARPI No

RADIALIS

25020 DECOMPRESS FOREARM No

1 SPACE

25023 DECOMPRESS FOREARM No

1 SPACE

25024 DECOMPRESS FOREARM No

2 SPACES

25025 DECOMPRESS FOREARM No

2 SPACES

25028 DRAINAGE OF FOREARM No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 897 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25031 DRAINAGE OF FOREARM No

BURSA

25035 TREAT FOREARM BONE No

LESION

25040 EXPLORE/TREAT WRIST No

JOINT

25065 BIOPSY FOREARM SOFT No

TISSUES

25066 BIOPSY FOREARM SOFT No

TISSUES

25071 EXC FOREARM LES SC 3 No

CM/>

25073 EXC FOREARM TUM DEEP No

3 CM/>

25075 EXC FOREARM LES SC < 3 No

CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 898 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25076 EXC FOREARM TUM DEEP No

< 3 CM

25077 RESECT FOREARM/WRIST No

TUM<3CM

25078 RESECT FORARM/WRIST No

TUM 3CM>

25085 INCISION OF WRIST No

CAPSULE

25100 BIOPSY OF WRIST JOINT No

25101 EXPLORE/TREAT WRIST No* *PA req'd if performed as elective proc in

JOINT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25105 REMOVE WRIST JOINT No

LINING

25107 REMOVE WRIST JOINT No* *PA req'd if performed as elective proc in
CARTILAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 899 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25109 EXCISE TENDON No

FOREARM/WRIST

25110 REMOVE WRIST TENDON No

LESION

25111 REMOVE WRIST TENDON No* *PA req'd if performed as elective proc in
LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25112 REREMOVE WRIST No* *PA req'd if performed as elective proc in

TENDON LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25115 REMOVE No
WRIST/FOREARM LESION

25116 REMOVE No
WRIST/FOREARM LESION

25118 EXCISE WRIST TENDON No

SHEATH

25119 PARTIAL REMOVAL OF No

ULNA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 900 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25120 REMOVAL OF FOREARM No

LESION

25125 REMOVE/GRAFT No
FOREARM LESION

25126 REMOVE/GRAFT No
FOREARM LESION

25130 REMOVAL OF WRIST No

LESION

25135 REMOVE & GRAFT WRIST No

LESION

25136 REMOVE & GRAFT WRIST No

LESION

25145 REMOVE FOREARM No

BONE LESION

25150 PARTIAL REMOVAL OF No

ULNA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 901 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25151 PARTIAL REMOVAL OF No

RADIUS

25170 RESECT RADIUS/ULNAR No

TUMOR

25210 REMOVAL OF WRIST No

BONE

25215 REMOVAL OF WRIST No

BONES

25230 PARTIAL REMOVAL OF No

RADIUS

25240 PARTIAL REMOVAL OF No

ULNA

25246 INJECTION FOR WRIST X- No

RAY

25248 REMOVE FOREARM No

FOREIGN BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 902 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25250 REMOVAL OF WRIST No

PROSTHESIS

25251 REMOVAL OF WRIST No

PROSTHESIS

25259 MANIPULATE WRIST No

W/ANESTHES

25260 REPAIR FOREARM No

TENDON/MUSCLE

25263 REPAIR FOREARM No

TENDON/MUSCLE

25265 REPAIR FOREARM No

TENDON/MUSCLE

25270 REPAIR FOREARM No

TENDON/MUSCLE

25272 REPAIR FOREARM No

TENDON/MUSCLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 903 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25274 REPAIR FOREARM No

TENDON/MUSCLE

25275 REPAIR FOREARM No

TENDON SHEATH

25280 REVISE WRIST/FOREARM No

TENDON

25290 INCISE WRIST/FOREARM No

TENDON

25295 RELEASE No
WRIST/FOREARM
TENDON

25300 FUSION OF TENDONS AT No

WRIST

25301 FUSION OF TENDONS AT No

WRIST

25310 TRANSPLANT FOREARM No* *PA req'd if performed as elective proc in

TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 904 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25312 TRANSPLANT FOREARM No* *PA req'd if performed as elective proc in

TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25315 REVISE PALSY HAND No* *PA req'd if performed as elective proc in
TENDON(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25316 REVISE PALSY HAND No* *PA req'd if performed as elective proc in
TENDON(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25320 REPAIR/REVISE WRIST No* *PA req'd if performed as elective proc in

JOINT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25332 REVISE WRIST JOINT No

25335 REALIGNMENT OF HAND No

25337 RECONSTRUCT No* *PA req'd if performed as elective proc in

ULNA/RADIOULNAR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25350 REVISION OF RADIUS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 905 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25355 REVISION OF RADIUS No

25360 REVISION OF ULNA No

25365 REVISE RADIUS & ULNA No

25370 REVISE RADIUS OR ULNA No

25375 REVISE RADIUS & ULNA No

25390 SHORTEN RADIUS OR No

ULNA

25391 LENGTHEN RADIUS OR No

ULNA

25392 SHORTEN RADIUS & ULNA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 906 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25393 LENGTHEN RADIUS & No

ULNA

25394 REPAIR CARPAL BONE No

SHORTEN

25400 REPAIR RADIUS OR ULNA No

25405 REPAIR/GRAFT RADIUS No

OR ULNA

25415 REPAIR RADIUS & ULNA No

25420 REPAIR/GRAFT RADIUS & No

ULNA

25425 REPAIR/GRAFT RADIUS No

OR ULNA

25426 REPAIR/GRAFT RADIUS & No

ULNA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 907 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25430 VASC GRAFT INTO No

CARPAL BONE

25431 REPAIR NONUNION No

CARPAL BONE

25440 REPAIR/GRAFT WRIST No

BONE

25441 RECONSTRUCT WRIST Yes InterQual® criteria used. Provide clinical

NH-IQ - Wrist
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

25442 RECONSTRUCT WRIST No

JOINT

25443 RECONSTRUCT WRIST No

JOINT

25444 RECONSTRUCT WRIST No

JOINT

25445 RECONSTRUCT WRIST No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 908 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25446 WRIST REPLACEMENT No

25447 REPAIR WRIST JOINTS No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25449 REMOVE WRIST JOINT No

IMPLANT

25450 REVISION OF WRIST JOINT No

25455 REVISION OF WRIST JOINT No

25490 REINFORCE RADIUS No

25491 REINFORCE ULNA No

25492 REINFORCE RADIUS AND No

ULNA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 909 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25500 TREAT FRACTURE OF No

RADIUS

25505 TREAT FRACTURE OF No* *PA req'd if performed as elective proc in

RADIUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25515 TREAT FRACTURE OF No* *PA req'd if performed as elective proc in

RADIUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25520 TREAT FRACTURE OF No

RADIUS

25525 TREAT FRACTURE OF No* *PA req'd if performed as elective proc in

RADIUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25526 TREAT FRACTURE OF No* *PA req'd if performed as elective proc in

RADIUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25530 TREAT FRACTURE OF No

ULNA

25535 TREAT FRACTURE OF No

ULNA

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 910 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25545 TREAT FRACTURE OF No

ULNA

25560 TREAT FRACTURE RADIUS No

& ULNA

25565 TREAT FRACTURE RADIUS No

& ULNA

25574 TREAT FRACTURE RADIUS No* *PA req'd if performed as elective proc in
& ULNA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25575 TREAT FRACTURE No* *PA req'd if performed as elective proc in

RADIUS/ULNA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25600 TREAT FRACTURE No

RADIUS/ULNA

25605 TREAT FRACTURE No

RADIUS/ULNA

25606 TREAT FX DISTAL RADIAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 911 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25607 TREAT FX RAD EXTRA- No

ARTICUL

25608 TREAT FX RAD INTRA- No

ARTICUL

25609 TREAT FX RADIAL 3+ FRAG No

25622 TREAT WRIST BONE No

FRACTURE

25624 TREAT WRIST BONE No

FRACTURE

25628 TREAT WRIST BONE No* *PA req'd if performed as elective proc in
FRACTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25630 TREAT WRIST BONE No

FRACTURE

25635 TREAT WRIST BONE No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 912 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25645 TREAT WRIST BONE No

FRACTURE

25650 TREAT WRIST BONE No

FRACTURE

25651 PIN ULNAR STYLOID No

FRACTURE

25652 TREAT FRACTURE ULNAR No

STYLOID

25660 TREAT WRIST No

DISLOCATION

25670 TREAT WRIST No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25671 PIN RADIOULNAR No

DISLOCATION

25675 TREAT WRIST No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 913 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25676 TREAT WRIST No

DISLOCATION

25680 TREAT WRIST FRACTURE No

25685 TREAT WRIST FRACTURE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25690 TREAT WRIST No

DISLOCATION

25695 TREAT WRIST No* *PA req'd if performed as elective proc in

DISLOCATION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

25800 FUSION OF WRIST JOINT No

25805 FUSION/GRAFT OF WRIST No

JOINT

25810 FUSION/GRAFT OF WRIST No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 914 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25820 FUSION OF HAND BONES No

25825 FUSE HAND BONES WITH No

GRAFT

25830 FUSION RADIOULNAR No

JNT/ULNA

25900 AMPUTATION OF No
FOREARM

25905 AMPUTATION OF No
FOREARM

25907 AMPUTATION FOLLOW- No

UP SURGERY

25909 AMPUTATION FOLLOW- No

UP SURGERY

25915 AMPUTATION OF No
FOREARM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 915 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

25920 AMPUTATE HAND AT No

WRIST

25922 AMPUTATE HAND AT No

WRIST

25924 AMPUTATION FOLLOW- No

UP SURGERY

25927 AMPUTATION OF HAND No

25929 AMPUTATION FOLLOW- No

UP SURGERY

25931 AMPUTATION FOLLOW- No

UP SURGERY

25999 FOREARM OR WRIST No

SURGERY

26010 DRAINAGE OF FINGER No

ABSCESS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 916 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26011 DRAINAGE OF FINGER No

ABSCESS

26020 DRAIN HAND TENDON No

SHEATH

26025 DRAINAGE OF PALM No

BURSA

26030 DRAINAGE OF PALM No

BURSAS

26034 TREAT HAND BONE No

LESION

26035 DECOMPRESS No
FINGERS/HAND

26037 DECOMPRESS No
FINGERS/HAND

26040 RELEASE PALM No

CONTRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 917 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26045 RELEASE PALM No

CONTRACTURE

26055 INCISE FINGER TENDON No* *PA req'd if performed as elective proc in
SHEATH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26060 INCISION OF FINGER No

TENDON

26070 EXPLORE/TREAT HAND No

JOINT

26075 EXPLORE/TREAT FINGER No

JOINT

26080 EXPLORE/TREAT FINGER No

JOINT

26100 BIOPSY HAND JOINT No

LINING

26105 BIOPSY FINGER JOINT No

LINING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 918 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26110 BIOPSY FINGER JOINT No

LINING

26111 EXC HAND LES SC 1.5 No

CM/>

26113 EXC HAND TUM DEEP 1.5 No

CM/>

26115 EXC HAND LES SC < 1.5 No

CM

26116 EXC HAND TUM DEEP < No

1.5 CM

26117 RAD RESECT HAND No

TUMOR < 3 CM

26118 RAD RESECT HAND No

TUMOR 3 CM/>

26121 RELEASE PALM No* *PA req'd if performed as elective proc in

CONTRACTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 919 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26123 RELEASE PALM No* *PA req'd if performed as elective proc in

CONTRACTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26125 RELEASE PALM No* *PA req'd if performed as elective proc in

CONTRACTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26130 REMOVE WRIST JOINT No

LINING

26135 REVISE FINGER JOINT No

EACH

26140 REVISE FINGER JOINT No

EACH

26145 TENDON EXCISION No

PALM/FINGER

26160 REMOVE TENDON No* *PA req'd if performed as elective proc in

SHEATH LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26170 REMOVAL OF PALM No

TENDON EACH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 920 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26180 REMOVAL OF FINGER No

TENDON

26185 REMOVE FINGER BONE No

26200 REMOVE HAND BONE No

LESION

26205 REMOVE/GRAFT BONE No

LESION

26210 REMOVAL OF FINGER No

LESION

26215 REMOVE/GRAFT FINGER No

LESION

26230 PARTIAL REMOVAL OF No

HAND BONE

26235 PARTIAL REMOVAL No

FINGER BONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 921 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26236 PARTIAL REMOVAL No

FINGER BONE

26250 EXTENSIVE HAND No

SURGERY

26260 RESECT PROX FINGER No

TUMOR

26262 RESECT DISTAL FINGER No

TUMOR

26320 REMOVAL OF IMPLANT No

FROM HAND

26340 MANIPULATE FINGER No

W/ANESTH

26341 MANIPULAT PALM CORD No

POST INJ

26350 REPAIR FINGER/HAND No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 922 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26352 REPAIR/GRAFT HAND No

TENDON

26356 REPAIR FINGER/HAND No

TENDON

26357 REPAIR FINGER/HAND No

TENDON

26358 REPAIR/GRAFT HAND No

TENDON

26370 REPAIR FINGER/HAND No

TENDON

26372 REPAIR/GRAFT HAND No

TENDON

26373 REPAIR FINGER/HAND No

TENDON

26390 REVISE HAND/FINGER No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 923 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26392 REPAIR/GRAFT HAND No

TENDON

26410 REPAIR HAND TENDON No

26412 REPAIR/GRAFT HAND No

TENDON

26415 EXCISION HAND/FINGER No

TENDON

26416 GRAFT HAND OR FINGER No

TENDON

26418 REPAIR FINGER TENDON No

26420 REPAIR/GRAFT FINGER No

TENDON

26426 REPAIR FINGER/HAND No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 924 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26428 REPAIR/GRAFT FINGER No

TENDON

26432 REPAIR FINGER TENDON No

26433 REPAIR FINGER TENDON No

26434 REPAIR/GRAFT FINGER No

TENDON

26437 REALIGNMENT OF No
TENDONS

26440 RELEASE PALM/FINGER No

TENDON

26442 RELEASE PALM & FINGER No

TENDON

26445 RELEASE HAND/FINGER No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 925 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26449 RELEASE No
FOREARM/HAND TENDON

26450 INCISION OF PALM No

TENDON

26455 INCISION OF FINGER No

TENDON

26460 INCISE HAND/FINGER No

TENDON

26471 FUSION OF FINGER No

TENDONS

26474 FUSION OF FINGER No

TENDONS

26476 TENDON LENGTHENING No

26477 TENDON SHORTENING No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 926 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26478 LENGTHENING OF HAND No

TENDON

26479 SHORTENING OF HAND No

TENDON

26480 TRANSPLANT HAND No* *PA req'd if performed as elective proc in

TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26483 TRANSPLANT/GRAFT No* *PA req'd if performed as elective proc in

HAND TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26485 TRANSPLANT PALM No* *PA req'd if performed as elective proc in

TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26489 TRANSPLANT/GRAFT No* *PA req'd if performed as elective proc in

PALM TENDON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26490 REVISE THUMB TENDON No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26492 TENDON TRANSFER WITH No* *PA req'd if performed as elective proc in
GRAFT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 927 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26494 HAND TENDON/MUSCLE No

TRANSFER

26496 REVISE THUMB TENDON No

26497 FINGER TENDON No* *PA req'd if performed as elective proc in

TRANSFER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26498 FINGER TENDON No* *PA req'd if performed as elective proc in

TRANSFER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26499 REVISION OF FINGER No

26500 HAND TENDON No

RECONSTRUCTION

26502 HAND TENDON No

RECONSTRUCTION

26508 RELEASE THUMB No

CONTRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 928 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26510 THUMB TENDON No

TRANSFER

26516 FUSION OF KNUCKLE No

JOINT

26517 FUSION OF KNUCKLE No

JOINTS

26518 FUSION OF KNUCKLE No

JOINTS

26520 RELEASE KNUCKLE No

CONTRACTURE

26525 RELEASE FINGER No

CONTRACTURE

26530 REVISE KNUCKLE JOINT No

26531 REVISE KNUCKLE WITH Yes Provide clinical documentation supporting

IQ - Hand and
IMPLANT rationale for request (e.g., notes, lab
Finger Surgery values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 929 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26535 REVISE FINGER JOINT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

26536 REVISE/IMPLANT FINGER Yes Provide clinical documentation supporting

IQ - Hand and
JOINT rationale for request (e.g., notes, lab
Finger Surgery values, X-rays, etc.)

26540 REPAIR HAND JOINT No

26541 REPAIR HAND JOINT No

WITH GRAFT

26542 REPAIR HAND JOINT No

WITH GRAFT

26545 RECONSTRUCT FINGER No

JOINT

26546 REPAIR NONUNION HAND No

26548 RECONSTRUCT FINGER No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 930 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26550 CONSTRUCT THUMB No

REPLACEMENT

26551 GREAT TOE-HAND No

TRANSFER

26553 SINGLE TRANSFER TOE- No

HAND

26554 DOUBLE TRANSFER TOE- No

HAND

26555 POSITIONAL CHANGE OF No

FINGER

26556 TOE JOINT TRANSFER No

26560 REPAIR OF WEB FINGER No

26561 REPAIR OF WEB FINGER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 931 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26562 REPAIR OF WEB FINGER No

26565 CORRECT METACARPAL No

FLAW

26567 CORRECT FINGER No

DEFORMITY

26568 LENGTHEN No
METACARPAL/FINGER

26580 REPAIR HAND DEFORMITY No

26587 RECONSTRUCT EXTRA No

FINGER

26590 REPAIR FINGER No

DEFORMITY

26591 REPAIR MUSCLES OF No

HAND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 932 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26593 RELEASE MUSCLES OF No

HAND

26596 EXCISION CONSTRICTING No

TISSUE

26600 TREAT METACARPAL No

FRACTURE

26605 TREAT METACARPAL No

FRACTURE

26607 TREAT METACARPAL No

FRACTURE

26608 TREAT METACARPAL No

FRACTURE

26615 TREAT METACARPAL No

FRACTURE

26641 TREAT THUMB No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 933 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26645 TREAT THUMB FRACTURE No

26650 TREAT THUMB FRACTURE No

26665 TREAT THUMB FRACTURE No

26670 TREAT HAND No

DISLOCATION

26675 TREAT HAND No

DISLOCATION

26676 PIN HAND DISLOCATION No

26685 TREAT HAND No

DISLOCATION

26686 TREAT HAND No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 934 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26700 TREAT KNUCKLE No

DISLOCATION

26705 TREAT KNUCKLE No

DISLOCATION

26706 PIN KNUCKLE No

DISLOCATION

26715 TREAT KNUCKLE No

DISLOCATION

26720 TREAT FINGER FRACTURE No

EACH

26725 TREAT FINGER FRACTURE No

EACH

26727 TREAT FINGER FRACTURE No

EACH

26735 TREAT FINGER FRACTURE No

EACH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 935 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26740 TREAT FINGER FRACTURE No

EACH

26742 TREAT FINGER FRACTURE No

EACH

26746 TREAT FINGER FRACTURE No

EACH

26750 TREAT FINGER FRACTURE No

EACH

26755 TREAT FINGER FRACTURE No

EACH

26756 PIN FINGER FRACTURE No

EACH

26765 TREAT FINGER FRACTURE No

EACH

26770 TREAT FINGER No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 936 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26775 TREAT FINGER No

DISLOCATION

26776 PIN FINGER DISLOCATION No

26785 TREAT FINGER No

DISLOCATION

26820 THUMB FUSION WITH No

GRAFT

26841 FUSION OF THUMB No

26842 THUMB FUSION WITH No

GRAFT

26843 FUSION OF HAND JOINT No

26844 FUSION/GRAFT OF HAND No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 937 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26850 FUSION OF KNUCKLE No

26852 FUSION OF KNUCKLE No

WITH GRAFT

26860 FUSION OF FINGER JOINT No

26861 FUSION OF FINGER JNT No

ADD-ON

26862 FUSION/GRAFT OF No
FINGER JOINT

26863 FUSE/GRAFT ADDED No

JOINT

26910 AMPUTATE METACARPAL No

BONE

26951 AMPUTATION OF No
FINGER/THUMB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 938 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

26952 AMPUTATION OF No
FINGER/THUMB

26989 HAND/FINGER SURGERY No

26990 DRAINAGE OF PELVIS No

LESION

26991 DRAINAGE OF PELVIS No

BURSA

26992 DRAINAGE OF BONE No

LESION

27000 INCISION OF HIP TENDON No

27001 INCISION OF HIP TENDON No

27003 INCISION OF HIP TENDON No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 939 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27005 INCISION OF HIP TENDON No

27006 INCISION OF HIP No

TENDONS

27025 INCISION OF HIP/THIGH No

FASCIA

27027 BUTTOCK FASCIOTOMY No

27030 DRAINAGE OF HIP JOINT No

27033 EXPLORATION OF HIP No

JOINT

27035 DENERVATION OF HIP No

JOINT

27036 EXCISION OF HIP No

JOINT/MUSCLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 940 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27040 BIOPSY OF SOFT TISSUES No

27041 BIOPSY OF SOFT TISSUES No

27043 EXC HIP PELVIS LES SC 3 No

CM/>

27045 EXC HIP/PELV TUM DEEP No

5 CM/>

27047 EXC HIP/PELVIS LES SC < No

3 CM

27048 EXC HIP/PELV TUM DEEP No

< 5 CM

27049 RESECT HIP/PELV TUM < No

5 CM

27050 BIOPSY OF SACROILIAC No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 941 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27052 BIOPSY OF HIP JOINT No

27054 REMOVAL OF HIP JOINT No

LINING

27057 BUTTOCK FASCIOTOMY No

W/DBRDMT

27059 RESECT HIP/PELV TUM 5 No

CM/>

27060 REMOVAL OF ISCHIAL No

BURSA

27062 REMOVE FEMUR No

LESION/BURSA

27065 REMOVE HIP BONE LES No

SUPER

27066 REMOVE HIP BONE LES No

DEEP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 942 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27067 REMOVE/GRAFT HIP No

BONE LESION

27070 PART REMOVE HIP BONE No

SUPER

27071 PART REMOVAL HIP No

BONE DEEP

27075 RESECT HIP TUMOR No

27076 RESECT HIP TUM INCL No

ACETABUL

27077 RESECT HIP TUM No

W/INNOM BONE

27078 RSECT HIP TUM INCL No

FEMUR

27080 REMOVAL OF TAIL BONE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 943 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27086 REMOVE HIP FOREIGN No

BODY

27087 REMOVE HIP FOREIGN No

BODY

27090 REMOVAL OF HIP No

PROSTHESIS

27091 REMOVAL OF HIP No

PROSTHESIS

27093 INJECTION FOR HIP X-RAY No

27095 INJECTION FOR HIP X-RAY No

27096 INJECT SACROILIAC JOINT Yes* Please review BMCHP criteria for details. Sacroiliac Joint Injections Sacroiliac Joint Injections (Eff
NH-Sacroilliac
*Will be covered only when performed in 05/01/18)
Joint Injection the Outpatient setting.

27097 REVISION OF HIP TENDON No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 944 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27098 TRANSFER TENDON TO No

PELVIS

27100 TRANSFER OF No
ABDOMINAL MUSCLE

27105 TRANSFER OF SPINAL No

MUSCLE

27110 TRANSFER OF ILIOPSOAS No

MUSCLE

27111 TRANSFER OF ILIOPSOAS No

MUSCLE

27120 RECONSTRUCTION OF No
HIP SOCKET

27122 RECONSTRUCTION OF Yes Provide clinical documentation supporting

IQ - Hip
HIP SOCKET rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

27125 PARTIAL HIP Yes InterQual® criteria used. Provide clinical

IQ - Hip
REPLACEMENT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 945 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27130 TOTAL HIP Yes InterQual® criteria used. Provide clinical

IQ - Hip
ARTHROPLASTY documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27132 TOTAL HIP Yes InterQual® criteria used. Provide clinical

IQ - Hip
ARTHROPLASTY documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27134 REVISE HIP JOINT Yes InterQual® criteria used. Provide clinical
IQ - Hip
REPLACEMENT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27137 REVISE HIP JOINT Yes InterQual® criteria used. Provide clinical
IQ - Hip
REPLACEMENT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27138 REVISE HIP JOINT Yes InterQual® criteria used. Provide clinical
IQ - Hip
REPLACEMENT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27140 TRANSPLANT FEMUR No

RIDGE

27146 INCISION OF HIP BONE No

27147 REVISION OF HIP BONE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 946 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27151 INCISION OF HIP BONES No

27156 REVISION OF HIP BONES No

27158 REVISION OF PELVIS No

27161 INCISION OF NECK OF No

FEMUR

27165 INCISION/FIXATION OF No
FEMUR

27170 REPAIR/GRAFT FEMUR No

HEAD/NECK

27175 TREAT SLIPPED EPIPHYSIS No

27176 TREAT SLIPPED EPIPHYSIS No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 947 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27177 TREAT SLIPPED EPIPHYSIS No

27178 TREAT SLIPPED EPIPHYSIS No

27179 REVISE HEAD/NECK OF No

FEMUR

27181 TREAT SLIPPED EPIPHYSIS No

27185 REVISION OF FEMUR No

EPIPHYSIS

27187 REINFORCE HIP BONES No

27193 TREAT PELVIC RING No

FRACTURE

27194 TREAT PELVIC RING No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 948 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27200 TREAT TAIL BONE No

FRACTURE

27202 TREAT TAIL BONE No

FRACTURE

27215 TREAT PELVIC No

FRACTURE(S)

27216 TREAT PELVIC RING No

FRACTURE

27217 TREAT PELVIC RING No

FRACTURE

27218 TREAT PELVIC RING No

FRACTURE

27220 TREAT HIP SOCKET No

FRACTURE

27222 TREAT HIP SOCKET No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 949 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27226 TREAT HIP WALL No

FRACTURE

27227 TREAT HIP FRACTURE(S) No

27228 TREAT HIP FRACTURE(S) No

27230 TREAT THIGH FRACTURE No

27232 TREAT THIGH FRACTURE No

27235 TREAT THIGH FRACTURE No

27236 TREAT THIGH FRACTURE No

27238 TREAT THIGH FRACTURE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 950 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27240 TREAT THIGH FRACTURE No

27244 TREAT THIGH FRACTURE No

27245 TREAT THIGH FRACTURE No

27246 TREAT THIGH FRACTURE No

27248 TREAT THIGH FRACTURE No

27250 TREAT HIP DISLOCATION No

27252 TREAT HIP DISLOCATION No

27253 TREAT HIP DISLOCATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 951 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27254 TREAT HIP DISLOCATION No

27256 TREAT HIP DISLOCATION No

27257 TREAT HIP DISLOCATION No

27258 TREAT HIP DISLOCATION No

27259 TREAT HIP DISLOCATION No

27265 TREAT HIP DISLOCATION No

27266 TREAT HIP DISLOCATION No

27267 CLTX THIGH FX No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 952 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27268 CLTX THIGH FX W/MNPJ No

27269 OPTX THIGH FX No

27275 MANIPULATION OF HIP No

JOINT

27279 ARTHRODESIS No
SACROILIAC JOINT

27280 FUSION OF SACROILIAC No

JOINT

27282 FUSION OF PUBIC BONES No

27284 FUSION OF HIP JOINT No

27286 FUSION OF HIP JOINT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 953 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27290 AMPUTATION OF LEG AT No

HIP

27295 AMPUTATION OF LEG AT No

HIP

27299 PELVIS/HIP JOINT No

SURGERY

27301 DRAIN THIGH/KNEE No

LESION

27303 DRAINAGE OF BONE No

LESION

27305 INCISE THIGH TENDON & No

FASCIA

27306 INCISION OF THIGH No

TENDON

27307 INCISION OF THIGH No

TENDONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 954 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27310 EXPLORATION OF KNEE No

JOINT

27323 BIOPSY THIGH SOFT No

TISSUES

27324 BIOPSY THIGH SOFT No

TISSUES

27325 NEURECTOMY No
HAMSTRING

27326 NEURECTOMY POPLITEAL No

27327 EXC THIGH/KNEE LES SC < No

3 CM

27328 EXC THIGH/KNEE TUM No

DEEP <5CM

27329 RESECT THIGH/KNEE No

TUM < 5 CM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 955 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27330 BIOPSY KNEE JOINT No

LINING

27331 EXPLORE/TREAT KNEE No

JOINT

27332 REMOVAL OF KNEE No

CARTILAGE

27333 REMOVAL OF KNEE No

CARTILAGE

27334 REMOVE KNEE JOINT No

LINING

27335 REMOVE KNEE JOINT No

LINING

27337 EXC THIGH/KNEE LES SC 3 No

CM/>

27339 EXC THIGH/KNEE TUM No

DEP 5CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 956 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27340 REMOVAL OF KNEECAP No

BURSA

27345 REMOVAL OF KNEE CYST No

27347 REMOVE KNEE CYST No

27350 REMOVAL OF KNEECAP No

27355 REMOVE FEMUR LESION No

27356 REMOVE FEMUR No

LESION/GRAFT

27357 REMOVE FEMUR No

LESION/GRAFT

27358 REMOVE FEMUR No

LESION/FIXATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 957 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27360 PARTIAL REMOVAL LEG No

BONE(S)

27364 RESECT THIGH/KNEE No

TUM 5 CM/>

27365 RESECT FEMUR/KNEE No

TUMOR

27370 INJECTION FOR KNEE X- No

RAY

27372 REMOVAL OF FOREIGN No

BODY

27380 REPAIR OF KNEECAP No

TENDON

27381 REPAIR/GRAFT KNEECAP No

TENDON

27385 REPAIR OF THIGH No

MUSCLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 958 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27386 REPAIR/GRAFT OF THIGH No

MUSCLE

27390 INCISION OF THIGH No

TENDON

27391 INCISION OF THIGH No

TENDONS

27392 INCISION OF THIGH No

TENDONS

27393 LENGTHENING OF THIGH No

TENDON

27394 LENGTHENING OF THIGH No

TENDONS

27395 LENGTHENING OF THIGH No

TENDONS

27396 TRANSPLANT OF THIGH No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 959 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27397 TRANSPLANTS OF THIGH No

TENDONS

27400 REVISE THIGH No

MUSCLES/TENDONS

27403 REPAIR OF KNEE No

CARTILAGE

27405 REPAIR OF KNEE No

LIGAMENT

27407 REPAIR OF KNEE No

LIGAMENT

27409 REPAIR OF KNEE No

LIGAMENTS

27412 AUTOCHONDROCYTE Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
IMPLANT KNEE more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

27415 OSTEOCHONDRAL KNEE Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
ALLOGRAFT more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 960 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27416 OSTEOCHONDRAL KNEE Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
AUTOGRAFT more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

27418 REPAIR DEGENERATED No

KNEECAP

27420 REVISION OF UNSTABLE No

KNEECAP

27422 REVISION OF UNSTABLE No

KNEECAP

27424 REVISION/REMOVAL OF No
KNEECAP

27425 LAT RETINACULAR No

RELEASE OPEN

27427 RECONSTRUCTION KNEE No

27428 RECONSTRUCTION KNEE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 961 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27429 RECONSTRUCTION KNEE No

27430 REVISION OF THIGH No

MUSCLES

27435 INCISION OF KNEE JOINT No

27437 REVISE KNEECAP No

27438 REVISE KNEECAP WITH No

IMPLANT

27440 REVISION OF KNEE JOINT No

27441 REVISION OF KNEE JOINT No

27442 REVISION OF KNEE JOINT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 962 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27443 REVISION OF KNEE JOINT No

27445 REVISION OF KNEE JOINT No

27446 REVISION OF KNEE JOINT Yes InterQual® criteria used. Provide clinical
IQ - Knee
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27447 TOTAL KNEE Yes InterQual® criteria used. Provide clinical

IQ - Knee
ARTHROPLASTY documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27448 INCISION OF THIGH No

27450 INCISION OF THIGH No

27454 REALIGNMENT OF THIGH No

BONE

27455 REALIGNMENT OF KNEE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 963 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27457 REALIGNMENT OF KNEE No

27465 SHORTENING OF THIGH No

BONE

27466 LENGTHENING OF THIGH No

BONE

27468 SHORTEN/LENGTHEN No
THIGHS

27470 REPAIR OF THIGH No

27472 REPAIR/GRAFT OF THIGH No

27475 SURGERY TO STOP LEG No

GROWTH

27477 SURGERY TO STOP LEG No

GROWTH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 964 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27479 SURGERY TO STOP LEG No

GROWTH

27485 SURGERY TO STOP LEG No

GROWTH

27486 REVISE/REPLACE KNEE Yes InterQual® criteria used. Provide clinical

IQ - Knee
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27487 REVISE/REPLACE KNEE Yes InterQual® criteria used. Provide clinical

IQ - Knee
JOINT documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

27488 REMOVAL OF KNEE Yes Provide clinical documentation supporting

IQ - Knee
PROSTHESIS rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

27495 REINFORCE THIGH No

27496 DECOMPRESSION OF No
THIGH/KNEE

27497 DECOMPRESSION OF No
THIGH/KNEE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 965 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27498 DECOMPRESSION OF No
THIGH/KNEE

27499 DECOMPRESSION OF No
THIGH/KNEE

27500 TREATMENT OF THIGH No

FRACTURE

27501 TREATMENT OF THIGH No

FRACTURE

27502 TREATMENT OF THIGH No

FRACTURE

27503 TREATMENT OF THIGH No

FRACTURE

27506 TREATMENT OF THIGH No

FRACTURE

27507 TREATMENT OF THIGH No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 966 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27508 TREATMENT OF THIGH No

FRACTURE

27509 TREATMENT OF THIGH No

FRACTURE

27510 TREATMENT OF THIGH No

FRACTURE

27511 TREATMENT OF THIGH No

FRACTURE

27513 TREATMENT OF THIGH No

FRACTURE

27514 TREATMENT OF THIGH No

FRACTURE

27516 TREAT THIGH FX No

GROWTH PLATE

27517 TREAT THIGH FX No

GROWTH PLATE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 967 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27519 TREAT THIGH FX No

GROWTH PLATE

27520 TREAT KNEECAP No

FRACTURE

27524 TREAT KNEECAP No

FRACTURE

27530 TREAT KNEE FRACTURE No

27532 TREAT KNEE FRACTURE No

27535 TREAT KNEE FRACTURE No

27536 TREAT KNEE FRACTURE No

27538 TREAT KNEE FRACTURE(S) No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 968 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27540 TREAT KNEE FRACTURE No

27550 TREAT KNEE No

DISLOCATION

27552 TREAT KNEE No

DISLOCATION

27556 TREAT KNEE No

DISLOCATION

27557 TREAT KNEE No

DISLOCATION

27558 TREAT KNEE No

DISLOCATION

27560 TREAT KNEECAP No

DISLOCATION

27562 TREAT KNEECAP No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 969 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27566 TREAT KNEECAP No

DISLOCATION

27570 FIXATION OF KNEE JOINT No

27580 FUSION OF KNEE No

27590 AMPUTATE LEG AT THIGH No

27591 AMPUTATE LEG AT THIGH No

27592 AMPUTATE LEG AT THIGH No

27594 AMPUTATION FOLLOW- No

UP SURGERY

27596 AMPUTATION FOLLOW- No

UP SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 970 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27598 AMPUTATE LOWER LEG No

AT KNEE

27599 LEG SURGERY No

PROCEDURE

27600 DECOMPRESSION OF No
LOWER LEG

27601 DECOMPRESSION OF No
LOWER LEG

27602 DECOMPRESSION OF No
LOWER LEG

27603 DRAIN LOWER LEG No

LESION

27604 DRAIN LOWER LEG BURSA No

27605 INCISION OF ACHILLES No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 971 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27606 INCISION OF ACHILLES No

TENDON

27607 TREAT LOWER LEG BONE No

LESION

27610 EXPLORE/TREAT ANKLE No

JOINT

27612 EXPLORATION OF ANKLE No

JOINT

27613 BIOPSY LOWER LEG SOFT No

TISSUE

27614 BIOPSY LOWER LEG SOFT No

TISSUE

27615 RESECT LEG/ANKLE TUM No

< 5 CM

27616 RESECT LEG/ANKLE TUM No

5 CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 972 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27618 EXC LEG/ANKLE TUM < 3 No

CM

27619 EXC LEG/ANKLE TUM No

DEEP <5 CM

27620 EXPLORE/TREAT ANKLE No

JOINT

27625 REMOVE ANKLE JOINT No

LINING

27626 REMOVE ANKLE JOINT No

LINING

27630 REMOVAL OF TENDON No* *PA req'd if performed as elective proc in

LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

27632 EXC LEG/ANKLE LES SC 3 No

CM/>

27634 EXC LEG/ANKLE TUM DEP No

5 CM/>

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 973 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27635 REMOVE LOWER LEG No

BONE LESION

27637 REMOVE/GRAFT LEG No

BONE LESION

27638 REMOVE/GRAFT LEG No

BONE LESION

27640 PARTIAL REMOVAL OF No

TIBIA

27641 PARTIAL REMOVAL OF No

FIBULA

27645 RESECT TIBIA TUMOR No

27646 RESECT FIBULA TUMOR No

27647 RESECT No
TALUS/CALCANEUS TUM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 974 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27648 INJECTION FOR ANKLE X- No

RAY

27650 REPAIR ACHILLES TENDON No

27652 REPAIR/GRAFT ACHILLES No

TENDON

27654 REPAIR OF ACHILLES No

TENDON

27656 REPAIR LEG FASCIA No

DEFECT

27658 REPAIR OF LEG TENDON No

EACH

27659 REPAIR OF LEG TENDON No

EACH

27664 REPAIR OF LEG TENDON No

EACH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 975 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27665 REPAIR OF LEG TENDON No

EACH

27675 REPAIR LOWER LEG No

TENDONS

27676 REPAIR LOWER LEG No

TENDONS

27680 RELEASE OF LOWER LEG No

TENDON

27681 RELEASE OF LOWER LEG No

TENDONS

27685 REVISION OF LOWER LEG No

TENDON

27686 REVISE LOWER LEG No

TENDONS

27687 REVISION OF CALF No

TENDON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 976 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27690 REVISE LOWER LEG No

TENDON

27691 REVISE LOWER LEG No

TENDON

27692 REVISE ADDITIONAL LEG No

TENDON

27695 REPAIR OF ANKLE No

LIGAMENT

27696 REPAIR OF ANKLE No

LIGAMENTS

27698 REPAIR OF ANKLE No

LIGAMENT

27700 REVISION OF ANKLE JOINT No

27702 RECONSTRUCT ANKLE No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 977 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27703 RECONSTRUCTION ANKLE No

JOINT

27704 REMOVAL OF ANKLE No

IMPLANT

27705 INCISION OF TIBIA No

27707 INCISION OF FIBULA No

27709 INCISION OF TIBIA & No

FIBULA

27712 REALIGNMENT OF No
LOWER LEG

27715 REVISION OF LOWER LEG No

27720 REPAIR OF TIBIA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 978 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27722 REPAIR/GRAFT OF TIBIA No

27724 REPAIR/GRAFT OF TIBIA No

27725 REPAIR OF LOWER LEG No

27726 REPAIR FIBULA No

NONUNION

27727 REPAIR OF LOWER LEG No

27730 REPAIR OF TIBIA No

EPIPHYSIS

27732 REPAIR OF FIBULA No

EPIPHYSIS

27734 REPAIR LOWER LEG No

EPIPHYSES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 979 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27740 REPAIR OF LEG EPIPHYSES No

27742 REPAIR OF LEG EPIPHYSES No

27745 REINFORCE TIBIA No

27750 TREATMENT OF TIBIA No

FRACTURE

27752 TREATMENT OF TIBIA No

FRACTURE

27756 TREATMENT OF TIBIA No

FRACTURE

27758 TREATMENT OF TIBIA No

FRACTURE

27759 TREATMENT OF TIBIA No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 980 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27760 CLTX MEDIAL ANKLE FX No

27762 CLTX MED ANKLE FX No

W/MNPJ

27766 OPTX MEDIAL ANKLE FX No

27767 CLTX POST ANKLE FX No

27768 CLTX POST ANKLE FX No

W/MNPJ

27769 OPTX POST ANKLE FX No

27780 TREATMENT OF FIBULA No

FRACTURE

27781 TREATMENT OF FIBULA No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 981 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27784 TREATMENT OF FIBULA No

FRACTURE

27786 TREATMENT OF ANKLE No

FRACTURE

27788 TREATMENT OF ANKLE No

FRACTURE

27792 TREATMENT OF ANKLE No

FRACTURE

27808 TREATMENT OF ANKLE No

FRACTURE

27810 TREATMENT OF ANKLE No

FRACTURE

27814 TREATMENT OF ANKLE No

FRACTURE

27816 TREATMENT OF ANKLE No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 982 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27818 TREATMENT OF ANKLE No

FRACTURE

27822 TREATMENT OF ANKLE No

FRACTURE

27823 TREATMENT OF ANKLE No

FRACTURE

27824 TREAT LOWER LEG No

FRACTURE

27825 TREAT LOWER LEG No

FRACTURE

27826 TREAT LOWER LEG No

FRACTURE

27827 TREAT LOWER LEG No

FRACTURE

27828 TREAT LOWER LEG No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 983 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27829 TREAT LOWER LEG JOINT No

27830 TREAT LOWER LEG No

DISLOCATION

27831 TREAT LOWER LEG No

DISLOCATION

27832 TREAT LOWER LEG No

DISLOCATION

27840 TREAT ANKLE No

DISLOCATION

27842 TREAT ANKLE No

DISLOCATION

27846 TREAT ANKLE No

DISLOCATION

27848 TREAT ANKLE No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 984 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27860 FIXATION OF ANKLE JOINT No

27870 FUSION OF ANKLE JOINT No

OPEN

27871 FUSION OF TIBIOFIBULAR No

JOINT

27880 AMPUTATION OF LOWER No

LEG

27881 AMPUTATION OF LOWER No

LEG

27882 AMPUTATION OF LOWER No

LEG

27884 AMPUTATION FOLLOW- No

UP SURGERY

27886 AMPUTATION FOLLOW- No

UP SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 985 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

27888 AMPUTATION OF FOOT No

AT ANKLE

27889 AMPUTATION OF FOOT No

AT ANKLE

27892 DECOMPRESSION OF LEG No

27893 DECOMPRESSION OF LEG No

27894 DECOMPRESSION OF LEG No

27899 LEG/ANKLE SURGERY No

PROCEDURE

28001 DRAINAGE OF BURSA OF No

FOOT

28002 TREATMENT OF FOOT No

INFECTION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 986 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28003 TREATMENT OF FOOT No

INFECTION

28005 TREAT FOOT BONE No

LESION

28008 INCISION OF FOOT FASCIA No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28010 INCISION OF TOE TENDON No

28011 INCISION OF TOE No

TENDONS

28020 EXPLORATION OF FOOT No

JOINT

28022 EXPLORATION OF FOOT No

JOINT

28024 EXPLORATION OF TOE No

JOINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 987 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28035 DECOMPRESSION OF No* *PA req'd if performed as elective proc in

TIBIA NERVE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28039 EXC FOOT/TOE TUM SC No

1.5 CM/>

28041 EXC FOOT/TOE TUM DEP No

1.5CM/>

28043 EXC FOOT/TOE TUM SC < No

1.5 CM

28045 EXC FOOT/TOE TUM No

DEEP <1.5CM

28046 RESECT FOOT/TOE No

TUMOR < 3 CM

28047 RESECT FOOT/TOE No

TUMOR 3 CM/>

28050 BIOPSY OF FOOT JOINT No

LINING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 988 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28052 BIOPSY OF FOOT JOINT No

LINING

28054 BIOPSY OF TOE JOINT No

LINING

28055 NEURECTOMY FOOT No

28060 PARTIAL REMOVAL FOOT No

FASCIA

28062 REMOVAL OF FOOT No

FASCIA

28070 REMOVAL OF FOOT No

JOINT LINING

28072 REMOVAL OF FOOT No

JOINT LINING

28080 REMOVAL OF FOOT No* *PA req'd if performed as elective proc in

LESION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 989 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28086 EXCISE FOOT TENDON No

SHEATH

28088 EXCISE FOOT TENDON No

SHEATH

28090 REMOVAL OF FOOT No

LESION

28092 REMOVAL OF TOE No

LESIONS

28100 REMOVAL OF No
ANKLE/HEEL LESION

28102 REMOVE/GRAFT FOOT No

LESION

28103 REMOVE/GRAFT FOOT No

LESION

28104 REMOVAL OF FOOT No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 990 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28106 REMOVE/GRAFT FOOT No

LESION

28107 REMOVE/GRAFT FOOT No

LESION

28108 REMOVAL OF TOE No

LESIONS

28110 PART REMOVAL OF No* *PA req'd if performed as elective proc in

METATARSAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28111 PART REMOVAL OF No

METATARSAL

28112 PART REMOVAL OF No

METATARSAL

28113 PART REMOVAL OF No

METATARSAL

28114 REMOVAL OF No
METATARSAL HEADS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 991 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28116 REVISION OF FOOT No

28118 REMOVAL OF HEEL BONE No

28119 REMOVAL OF HEEL SPUR No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28120 PART REMOVAL OF No

ANKLE/HEEL

28122 PARTIAL REMOVAL OF No

FOOT BONE

28124 PARTIAL REMOVAL OF No

TOE

28126 PARTIAL REMOVAL OF No

TOE

28130 REMOVAL OF ANKLE No

BONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 992 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28140 REMOVAL OF No
METATARSAL

28150 REMOVAL OF TOE No

28153 PARTIAL REMOVAL OF No

TOE

28160 PARTIAL REMOVAL OF No* *PA req'd if performed as elective proc in

TOE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28171 RESECT TARSAL TUMOR No

28173 RESECT METATARSAL No

TUMOR

28175 RESECT PHALANX OF TOE No

TUMOR

28190 REMOVAL OF FOOT No

FOREIGN BODY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 993 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28192 REMOVAL OF FOOT No

FOREIGN BODY

28193 REMOVAL OF FOOT No

FOREIGN BODY

28200 REPAIR OF FOOT TENDON No

28202 REPAIR/GRAFT OF FOOT No

TENDON

28208 REPAIR OF FOOT TENDON No

28210 REPAIR/GRAFT OF FOOT No

TENDON

28220 RELEASE OF FOOT No

TENDON

28222 RELEASE OF FOOT No

TENDONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 994 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28225 RELEASE OF FOOT No

TENDON

28226 RELEASE OF FOOT No

TENDONS

28230 INCISION OF FOOT No

TENDON(S)

28232 INCISION OF TOE TENDON No

28234 INCISION OF FOOT No

TENDON

28238 REVISION OF FOOT No

TENDON

28240 RELEASE OF BIG TOE No

28250 REVISION OF FOOT No* *PA req'd if performed as elective proc in

FASCIA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 995 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28260 RELEASE OF MIDFOOT No

JOINT

28261 REVISION OF FOOT No

TENDON

28262 REVISION OF FOOT AND No

ANKLE

28264 RELEASE OF MIDFOOT No

JOINT

28270 RELEASE OF FOOT No

CONTRACTURE

28272 RELEASE OF TOE JOINT No

EACH

28280 FUSION OF TOES No

28285 REPAIR OF HAMMERTOE No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 996 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28286 REPAIR OF HAMMERTOE No

28288 PARTIAL REMOVAL OF No* *PA req'd if performed as elective proc in

FOOT BONE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28289 CORRJ HALUX RIGDUS No

W/O IMPLT

28290 CORRECTION OF BUNION No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28292 CORRECTION HALLUX No* *PA req'd if performed as elective proc in

VALGUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28293 CORRECTION OF BUNION Yes Provide clinical documentation supporting

NH-IQ Foot
rationale for request (e.g., notes, lab
/Toe Surg values, X-rays, etc.)

28294 CORRECTION OF BUNION No

28296 CORRECTION HALLUX No* *PA req'd if performed as elective proc in

VALGUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 997 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28297 CORRECTION HALLUX No* *PA req'd if performed as elective proc in

VALGUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28298 CORRECTION HALLUX No

VALGUS

28299 CORRECTION HALLUX No

VALGUS

28300 INCISION OF HEEL BONE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28302 INCISION OF ANKLE BONE No

28304 INCISION OF MIDFOOT No

BONES

28305 INCISE/GRAFT MIDFOOT No

BONES

28306 INCISION OF No* *PA req'd if performed as elective proc in

METATARSAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 998 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28307 INCISION OF No
METATARSAL

28308 INCISION OF No* *PA req'd if performed as elective proc in

METATARSAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28309 INCISION OF No
METATARSALS

28310 REVISION OF BIG TOE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28312 REVISION OF TOE No

28313 REPAIR DEFORMITY OF No

TOE

28315 REMOVAL OF SESAMOID No

BONE

28320 REPAIR OF FOOT BONES No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 999 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28322 REPAIR OF METATARSALS No

28340 RESECT ENLARGED TOE No

TISSUE

28341 RESECT ENLARGED TOE No

28344 REPAIR EXTRA TOE(S) No

28345 REPAIR WEBBED TOE(S) No

28360 RECONSTRUCT CLEFT No

FOOT

28400 TREATMENT OF HEEL No

FRACTURE

28405 TREATMENT OF HEEL No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1000 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28406 TREATMENT OF HEEL No

FRACTURE

28415 TREAT HEEL FRACTURE No

28420 TREAT/GRAFT HEEL No

FRACTURE

28430 TREATMENT OF ANKLE No

FRACTURE

28435 TREATMENT OF ANKLE No

FRACTURE

28436 TREATMENT OF ANKLE No

FRACTURE

28445 TREAT ANKLE FRACTURE No

28446 OSTEOCHONDRAL TALUS Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
AUTOGRFT more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1001 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28450 TREAT MIDFOOT No

FRACTURE EACH

28455 TREAT MIDFOOT No

FRACTURE EACH

28456 TREAT MIDFOOT No

FRACTURE

28465 TREAT MIDFOOT No

FRACTURE EACH

28470 TREAT METATARSAL No

FRACTURE

28475 TREAT METATARSAL No

FRACTURE

28476 TREAT METATARSAL No

FRACTURE

28485 TREAT METATARSAL No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1002 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28490 TREAT BIG TOE FRACTURE No

28495 TREAT BIG TOE FRACTURE No

28496 TREAT BIG TOE FRACTURE No

28505 TREAT BIG TOE FRACTURE No

28510 TREATMENT OF TOE No

FRACTURE

28515 TREATMENT OF TOE No

FRACTURE

28525 TREAT TOE FRACTURE No

28530 TREAT SESAMOID BONE No

FRACTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1003 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28531 TREAT SESAMOID BONE No

FRACTURE

28540 TREAT FOOT No

DISLOCATION

28545 TREAT FOOT No

DISLOCATION

28546 TREAT FOOT No

DISLOCATION

28555 REPAIR FOOT No

DISLOCATION

28570 TREAT FOOT No

DISLOCATION

28575 TREAT FOOT No

DISLOCATION

28576 TREAT FOOT No

DISLOCATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1004 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28585 REPAIR FOOT No

DISLOCATION

28600 TREAT FOOT No

DISLOCATION

28605 TREAT FOOT No

DISLOCATION

28606 TREAT FOOT No

DISLOCATION

28615 REPAIR FOOT No

DISLOCATION

28630 TREAT TOE DISLOCATION No

28635 TREAT TOE DISLOCATION No

28636 TREAT TOE DISLOCATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1005 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28645 REPAIR TOE DISLOCATION No

28660 TREAT TOE DISLOCATION No

28665 TREAT TOE DISLOCATION No

28666 TREAT TOE DISLOCATION No

28675 REPAIR OF TOE No

DISLOCATION

28705 FUSION OF FOOT BONES No

28715 FUSION OF FOOT BONES No

28725 FUSION OF FOOT BONES No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1006 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28730 FUSION OF FOOT BONES No

28735 FUSION OF FOOT BONES No

28737 REVISION OF FOOT No

BONES

28740 FUSION OF FOOT BONES No

28750 FUSION OF BIG TOE JOINT No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

28755 FUSION OF BIG TOE JOINT No

28760 FUSION OF BIG TOE JOINT No

28800 AMPUTATION OF No
MIDFOOT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1007 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

28805 AMPUTATION THRU No

METATARSAL

28810 AMPUTATION TOE & No

METATARSAL

28820 AMPUTATION OF TOE No

28825 PARTIAL AMPUTATION No

OF TOE

28890 HI ENRGY ESWT PLANTAR Yes* InterQual® criteria used. *Will be covered
NH-IQ Foot
FASCIA only when performed in the Outpatient
/Toe Surg setting.

28899 FOOT/TOES SURGERY Yes* InterQual® criteria used. *Will be covered

NH-IQ Foot
PROCEDURE only when performed in the Outpatient
/Toe Surg setting.

29000 APPLICATION OF BODY No

CAST

29010 APPLICATION OF BODY No

CAST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1008 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29015 APPLICATION OF BODY No

CAST

29035 APPLICATION OF BODY No

CAST

29040 APPLICATION OF BODY No

CAST

29044 APPLICATION OF BODY No

CAST

29046 APPLICATION OF BODY No

CAST

29049 APPLICATION OF FIGURE No

EIGHT

29055 APPLICATION OF No
SHOULDER CAST

29058 APPLICATION OF No
SHOULDER CAST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1009 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29065 APPLICATION OF LONG No

ARM CAST

29075 APPLICATION OF No
FOREARM CAST

29085 APPLY HAND/WRIST CAST No

29086 APPLY FINGER CAST No

29105 APPLY LONG ARM SPLINT No

29125 APPLY FOREARM SPLINT No

29126 APPLY FOREARM SPLINT No

29130 APPLICATION OF FINGER No

SPLINT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1010 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29131 APPLICATION OF FINGER No

SPLINT

29200 STRAPPING OF CHEST No

29240 STRAPPING OF SHOULDER No

29260 STRAPPING OF ELBOW No

OR WRIST

29280 STRAPPING OF HAND OR No

FINGER

29305 APPLICATION OF HIP CAST No

29325 APPLICATION OF HIP No

CASTS

29345 APPLICATION OF LONG No

LEG CAST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1011 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29355 APPLICATION OF LONG No

LEG CAST

29358 APPLY LONG LEG CAST No

BRACE

29365 APPLICATION OF LONG No

LEG CAST

29405 APPLY SHORT LEG CAST No

29425 APPLY SHORT LEG CAST No

29435 APPLY SHORT LEG CAST No

29440 ADDITION OF WALKER TO No

CAST

29445 APPLY RIGID LEG CAST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1012 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29450 APPLICATION OF LEG No

CAST

29505 APPLICATION LONG LEG No

SPLINT

29515 APPLICATION LOWER LEG No

SPLINT

29520 STRAPPING OF HIP No

29530 STRAPPING OF KNEE No

29540 STRAPPING OF ANKLE No

AND/OR FT

29550 STRAPPING OF TOES No

29580 APPLICATION OF PASTE No

BOOT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1013 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29581 APPLY MULTLAY COMPRS No

LWR LEG

29582 APPLY MULTLAY COMPRS No

UPR LEG

29583 APPLY MULTLAY COMPRS No

UPR ARM

29584 APPL MULTLAY COMPRS No

ARM/HAND

29700 REMOVAL/REVISION OF No
CAST

29705 REMOVAL/REVISION OF No
CAST

29710 REMOVAL/REVISION OF No
CAST

29720 REPAIR OF BODY CAST No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1014 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29730 WINDOWING OF CAST No

29740 WEDGING OF CAST No

29750 WEDGING OF CLUBFOOT No

CAST

29799 CASTING/STRAPPING No
PROCEDURE

29800 JAW Yes* *PA required ONLY when diagnosis is TMJ. Temporomandibular Joint Disorder Temporomandibular Joint
ARTHROSCOPY/SURGERY Please review the BMCHP policies for Treatment Disorder Treatment ( Eff
more details 01/01/19)

29804 JAW Yes* Please review BMCHP criteria for details. Temporomandibular Joint Disorder Temporomandibular Joint
ARTHROSCOPY/SURGERY *Will be covered only when performed in Treatment Disorder Treatment ( Eff
the Outpatient setting. 01/01/19)

29805 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY DX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29806 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1015 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29807 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29819 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29820 SHOULDER No
ARTHROSCOPY/SURGERY

29821 SHOULDER No
ARTHROSCOPY/SURGERY

29822 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29823 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29824 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29825 SHOULDER No
ARTHROSCOPY/SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1016 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29826 SHOULDER No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29827 ARTHROSCOP ROTATOR No* *PA req'd if performed as elective proc in

CUFF REPR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29828 ARTHROSCOPY BICEPS No* *PA req'd if performed as elective proc in

TENODESIS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29830 ELBOW ARTHROSCOPY No

29834 ELBOW No
ARTHROSCOPY/SURGERY

29835 ELBOW No
ARTHROSCOPY/SURGERY

29836 ELBOW No
ARTHROSCOPY/SURGERY

29837 ELBOW No
ARTHROSCOPY/SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1017 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29838 ELBOW No
ARTHROSCOPY/SURGERY

29840 WRIST ARTHROSCOPY No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29843 WRIST No
ARTHROSCOPY/SURGERY

29844 WRIST No
ARTHROSCOPY/SURGERY

29845 WRIST No
ARTHROSCOPY/SURGERY

29846 WRIST No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29847 WRIST No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29848 WRIST No* *PA req'd if performed as elective proc in

ENDOSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1018 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29850 KNEE No
ARTHROSCOPY/SURGERY

29851 KNEE No
ARTHROSCOPY/SURGERY

29855 TIBIAL No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29856 TIBIAL No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29860 HIP ARTHROSCOPY DX No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29861 HIP ARTHRO W/FB No

REMOVAL

29862 HIP ARTHR0 No

W/DEBRIDEMENT

29863 HIP ARTHR0 No

W/SYNOVECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1019 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29866 AUTGRFT IMPLNT KNEE Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
W/SCOPE more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

29867 ALLGRFT IMPLNT KNEE Yes Please review the Well Sense Policy for Osteochondral Treatments for Osteochondral Treatments
NH-
W/SCOPE more details Defects of the Knee for Defects of the Knee (Eff
Osteochondral 03/01/18)
Defects
Treatment

29868 MENISCAL TRNSPL KNEE No

W/SCPE

29870 KNEE ARTHROSCOPY DX No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29871 KNEE No
ARTHROSCOPY/DRAINAG
E

29873 KNEE No
ARTHROSCOPY/SURGERY

29874 KNEE No
ARTHROSCOPY/SURGERY

29875 KNEE No
ARTHROSCOPY/SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1020 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29876 KNEE No
ARTHROSCOPY/SURGERY

29877 KNEE No
ARTHROSCOPY/SURGERY

29879 KNEE No
ARTHROSCOPY/SURGERY

29880 KNEE No
ARTHROSCOPY/SURGERY

29881 KNEE No
ARTHROSCOPY/SURGERY

29882 KNEE No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29883 KNEE No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29884 KNEE No
ARTHROSCOPY/SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1021 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29885 KNEE No
ARTHROSCOPY/SURGERY

29886 KNEE No
ARTHROSCOPY/SURGERY

29887 KNEE No
ARTHROSCOPY/SURGERY

29888 KNEE No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29889 KNEE No* *PA req'd if performed as elective proc in

ARTHROSCOPY/SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

29891 ANKLE No
ARTHROSCOPY/SURGERY

29892 ANKLE No
ARTHROSCOPY/SURGERY

29893 SCOPE PLANTAR No* *PA req'd if performed as elective proc in

FASCIOTOMY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1022 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29894 ANKLE No
ARTHROSCOPY/SURGERY

29895 ANKLE No
ARTHROSCOPY/SURGERY

29897 ANKLE No
ARTHROSCOPY/SURGERY

29898 ANKLE No
ARTHROSCOPY/SURGERY

29899 ANKLE No
ARTHROSCOPY/SURGERY

29900 MCP JOINT No

ARTHROSCOPY DX

29901 MCP JOINT No

ARTHROSCOPY SURG

29902 MCP JOINT No

ARTHROSCOPY SURG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1023 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

29904 SUBTALAR ARTHRO W/FB No InterQual® criteria is available

RMVL

29905 SUBTALAR ARTHRO No InterQual® criteria is available

W/EXC

29906 SUBTALAR ARTHRO No InterQual® criteria is available

W/DEB

29907 SUBTALAR ARTHRO No

W/FUSION

29914 HIP ARTHRO No

W/FEMOROPLASTY

29915 HIP ARTHRO No

ACETABULOPLASTY

29916 HIP ARTHRO W/LABRAL No

REPAIR

29999 ARTHROSCOPY OF JOINT No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1024 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

nervous system
61000 REMOVE CRANIAL No
CAVITY FLUID

61001 REMOVE CRANIAL No

CAVITY FLUID

61020 REMOVE BRAIN CAVITY No

FLUID

61026 INJECTION INTO BRAIN No

CANAL

61050 REMOVE BRAIN CANAL No

FLUID

61055 INJECTION INTO BRAIN No

CANAL

61070 BRAIN CANAL SHUNT No

PROCEDURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1025 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61105 TWIST DRILL HOLE No

61107 DRILL SKULL FOR No

IMPLANTATION

61108 DRILL SKULL FOR No

DRAINAGE

61120 BURR HOLE FOR No

PUNCTURE

61140 PIERCE SKULL FOR BIOPSY No

61150 PIERCE SKULL FOR No

DRAINAGE

61151 PIERCE SKULL FOR No

DRAINAGE

61154 PIERCE SKULL & REMOVE No

CLOT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1026 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61156 PIERCE SKULL FOR No

DRAINAGE

61210 PIERCE SKULL IMPLANT No

DEVICE

61215 INSERT BRAIN-FLUID No

DEVICE

61250 PIERCE SKULL & EXPLORE No

61253 PIERCE SKULL & EXPLORE No

61304 OPEN SKULL FOR No

EXPLORATION

61305 OPEN SKULL FOR No

EXPLORATION

61312 OPEN SKULL FOR No

DRAINAGE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1027 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61313 OPEN SKULL FOR No

DRAINAGE

61314 OPEN SKULL FOR No

DRAINAGE

61315 OPEN SKULL FOR No

DRAINAGE

61316 IMPLT CRAN BONE FLAP No

TO ABDO

61320 OPEN SKULL FOR No

DRAINAGE

61321 OPEN SKULL FOR No

DRAINAGE

61322 DECOMPRESSIVE No
CRANIOTOMY

61323 DECOMPRESSIVE No
LOBECTOMY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1028 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61330 DECOMPRESS EYE SOCKET No

61332 EXPLORE/BIOPSY EYE No

SOCKET

61333 EXPLORE ORBIT/REMOVE No

LESION

61340 SUBTEMPORAL No
DECOMPRESSION

61343 INCISE SKULL (PRESS No

RELIEF)

61345 RELIEVE CRANIAL No

PRESSURE

61450 INCISE SKULL FOR No

SURGERY

61458 INCISE SKULL FOR BRAIN No

WOUND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1029 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61460 INCISE SKULL FOR No

SURGERY

61480 INCISE SKULL FOR No

SURGERY

61500 REMOVAL OF SKULL No

LESION

61501 REMOVE INFECTED No

SKULL BONE

61510 REMOVAL OF BRAIN No

LESION

61512 REMOVE BRAIN LINING No

LESION

61514 REMOVAL OF BRAIN No

ABSCESS

61516 REMOVAL OF BRAIN No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1030 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61517 IMPLT BRAIN CHEMOTX No

ADD-ON

61518 REMOVAL OF BRAIN No

LESION

61519 REMOVE BRAIN LINING No

LESION

61520 REMOVAL OF BRAIN No

LESION

61521 REMOVAL OF BRAIN No

LESION

61522 REMOVAL OF BRAIN No

ABSCESS

61524 REMOVAL OF BRAIN No

LESION

61526 REMOVAL OF BRAIN No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1031 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61530 REMOVAL OF BRAIN No

LESION

61531 IMPLANT BRAIN No

ELECTRODES

61533 IMPLANT BRAIN No

ELECTRODES

61534 REMOVAL OF BRAIN No

LESION

61535 REMOVE BRAIN No

ELECTRODES

61536 REMOVAL OF BRAIN No

LESION

61537 REMOVAL OF BRAIN No

TISSUE

61538 REMOVAL OF BRAIN No

TISSUE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1032 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61539 REMOVAL OF BRAIN No

TISSUE

61540 REMOVAL OF BRAIN No

TISSUE

61541 INCISION OF BRAIN No

TISSUE

61543 REMOVAL OF BRAIN No

TISSUE

61544 REMOVE & TREAT BRAIN No

LESION

61545 EXCISION OF BRAIN No

TUMOR

61546 REMOVAL OF PITUITARY No

GLAND

61548 REMOVAL OF PITUITARY No

GLAND

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1033 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61550 RELEASE OF SKULL SEAMS No

61552 RELEASE OF SKULL SEAMS No

61556 INCISE SKULL/SUTURES No

61557 INCISE SKULL/SUTURES No

61558 EXCISION OF No
SKULL/SUTURES

61559 EXCISION OF No
SKULL/SUTURES

61563 EXCISION OF SKULL No

TUMOR

61564 EXCISION OF SKULL No

TUMOR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1034 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61566 REMOVAL OF BRAIN No

TISSUE

61567 INCISION OF BRAIN No

TISSUE

61570 REMOVE FOREIGN BODY No

BRAIN

61571 INCISE SKULL FOR BRAIN No

WOUND

61575 SKULL BASE/BRAINSTEM No

SURGERY

61576 SKULL BASE/BRAINSTEM No

SURGERY

61580 CRANIOFACIAL No
APPROACH SKULL

61581 CRANIOFACIAL No
APPROACH SKULL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1035 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61582 CRANIOFACIAL No
APPROACH SKULL

61583 CRANIOFACIAL No
APPROACH SKULL

61584 ORBITOCRANIAL No
APPROACH/SKULL

61585 ORBITOCRANIAL No
APPROACH/SKULL

61586 RESECT NASOPHARYNX No

SKULL

61590 INFRATEMPORAL No
APPROACH/SKULL

61591 INFRATEMPORAL No
APPROACH/SKULL

61592 ORBITOCRANIAL No
APPROACH/SKULL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1036 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61595 TRANSTEMPORAL No
APPROACH/SKULL

61596 TRANSCOCHLEAR No
APPROACH/SKULL

61597 TRANSCONDYLAR No
APPROACH/SKULL

61598 TRANSPETROSAL No
APPROACH/SKULL

61600 RESECT/EXCISE CRANIAL No

LESION

61601 RESECT/EXCISE CRANIAL No

LESION

61605 RESECT/EXCISE CRANIAL No

LESION

61606 RESECT/EXCISE CRANIAL No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1037 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61607 RESECT/EXCISE CRANIAL No

LESION

61608 RESECT/EXCISE CRANIAL No

LESION

61610 TRANSECT ARTERY SINUS No

61611 TRANSECT ARTERY SINUS No

61612 TRANSECT ARTERY SINUS No

61613 REMOVE ANEURYSM No

SINUS

61615 RESECT/EXCISE LESION No

SKULL

61616 RESECT/EXCISE LESION No

SKULL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1038 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61618 REPAIR DURA No

61619 REPAIR DURA No

61623 ENDOVASC TEMPORY No

VESSEL OCCL

61624 TRANSCATH OCCLUSION No

CNS

61626 TRANSCATH OCCLUSION No

NON-CNS

61630 INTRACRANIAL No
ANGIOPLASTY

61635 INTRACRAN ANGIOPLSTY No

W/STENT

61640 DILATE IC VASOSPASM No

INIT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1039 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61641 DILATE IC VASOSPASM No

ADD-ON

61642 DILATE IC VASOSPASM No

ADD-ON

61645 PERQ ART M- No

THROMBECT &/NFS

61650 EVASC PRLNG ADMN RX No

AGNT 1ST

61651 EVASC PRLNG ADMN RX No

AGNT ADD

61680 INTRACRANIAL VESSEL No

SURGERY

61682 INTRACRANIAL VESSEL No

SURGERY

61684 INTRACRANIAL VESSEL No

SURGERY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1040 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61686 INTRACRANIAL VESSEL No

SURGERY

61690 INTRACRANIAL VESSEL No

SURGERY

61692 INTRACRANIAL VESSEL No

SURGERY

61697 BRAIN ANEURYSM REPR No

COMPLX

61698 BRAIN ANEURYSM REPR No

COMPLX

61700 BRAIN ANEURYSM REPR No

SIMPLE

61702 INNER SKULL VESSEL No

SURGERY

61703 CLAMP NECK ARTERY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1041 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61705 REVISE CIRCULATION TO No

HEAD

61708 REVISE CIRCULATION TO No

HEAD

61710 REVISE CIRCULATION TO No

HEAD

61711 FUSION OF SKULL No

ARTERIES

61720 INCISE SKULL/BRAIN Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
SURGERY more details 11/01/18)
Neurosurgery

61735 INCISE SKULL/BRAIN Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
SURGERY more details 11/01/18)
Neurosurgery

61750 INCISE SKULL/BRAIN No

BIOPSY

61751 BRAIN BIOPSY W/CT/MR No

GUIDE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1042 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61760 IMPLANT BRAIN Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
IQ -
ELECTRODES more details 11/01/18)
Neurosurgery

61770 INCISE SKULL FOR No

TREATMENT

61781 SCAN PROC CRANIAL No

INTRA

61782 SCAN PROC CRANIAL No

EXTRA

61783 SCAN PROC SPINAL No

61790 TREAT TRIGEMINAL No

NERVE

61791 TREAT TRIGEMINAL No

TRACT

61796 SRS CRANIAL LESION Yes* InterQual® criteria used. *Will be covered
IQ -
SIMPLE only when performed in the Outpatient
Neurosurgery setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1043 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61797 SRS CRAN LES SIMPLE No* *PA req'd if performed as elective proc in
ADDL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

61798 SRS CRANIAL LESION Yes* InterQual® criteria used. *Will be covered
IQ -
COMPLEX only when performed in the Outpatient
Neurosurgery setting.

61799 SRS CRAN LES COMPLEX No* *PA req'd if performed as elective proc in
ADDL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

61800 APPLY SRS HEADFRAME No

ADD-ON

61850 IMPLANT No
NEUROELECTRODES

61860 IMPLANT No
NEUROELECTRODES

61863 IMPLANT Yes InterQual® criteria used. Provide clinical

IQ -
NEUROELECTRODE documentation supporting rationale for
Neurosurgery request (e.g., notes, lab values, X-rays, etc.)

61864 IMPLANT No
NEUROELECTRDE ADDL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1044 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

61867 IMPLANT Yes InterQual® criteria used. Provide clinical

IQ -
NEUROELECTRODE documentation supporting rationale for
Neurosurgery request (e.g., notes, lab values, X-rays, etc.)

61868 IMPLANT No
NEUROELECTRDE ADDL

61870 IMPLANT No
NEUROELECTRODES

61880 REVISE/REMOVE No
NEUROELECTRODE

61886 IMPLANT NEUROSTIM Yes Please review the Well Sense Policy for
NH-Vagus
ARRAYS more details
Nerve Stim

62000 TREAT SKULL FRACTURE No

62005 TREAT SKULL FRACTURE No

62010 TREATMENT OF HEAD No

INJURY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1045 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62100 REPAIR BRAIN FLUID No

LEAKAGE

62115 REDUCTION OF SKULL No

DEFECT

62117 REDUCTION OF SKULL No

DEFECT

62120 REPAIR SKULL CAVITY No

LESION

62121 INCISE SKULL REPAIR No

62140 REPAIR OF SKULL DEFECT No

62141 REPAIR OF SKULL DEFECT No

62142 REMOVE SKULL No

PLATE/FLAP

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1046 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62143 REPLACE SKULL No

PLATE/FLAP

62145 REPAIR OF SKULL & BRAIN No

62146 REPAIR OF SKULL WITH No

GRAFT

62147 REPAIR OF SKULL WITH No

GRAFT

62148 RETR BONE FLAP TO FIX No

SKULL

62160 NEUROENDOSCOPY ADD- No

ON

62161 DISSECT BRAIN W/SCOPE No

62162 REMOVE COLLOID CYST No

W/SCOPE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1047 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62163 ZNEUROENDOSCOPY No
W/FB REMOVAL

62164 REMOVE BRAIN TUMOR No

W/SCOPE

62165 REMOVE PITUIT TUMOR No

W/SCOPE

62180 ESTABLISH BRAIN CAVITY No

SHUNT

62190 ESTABLISH BRAIN CAVITY No

SHUNT

62192 ESTABLISH BRAIN CAVITY No

SHUNT

62194 REPLACE/IRRIGATE No
CATHETER

62200 ESTABLISH BRAIN CAVITY No

SHUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1048 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62201 BRAIN CAVITY SHUNT No

W/SCOPE

62220 ESTABLISH BRAIN CAVITY No

SHUNT

62223 ESTABLISH BRAIN CAVITY No

SHUNT

62225 REPLACE/IRRIGATE No
CATHETER

62230 REPLACE/REVISE BRAIN No

SHUNT

62252 CSF SHUNT REPROGRAM No

62256 REMOVE BRAIN CAVITY No

SHUNT

62258 REPLACE BRAIN CAVITY No

SHUNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1049 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62263 EPIDURAL LYSIS MULT No

SESSIONS

62264 EPIDURAL LYSIS ON No

SINGLE DAY

62267 INTERDISCAL PERQ ASPIR Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DX more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

62268 DRAIN SPINAL CORD CYST No

62269 NEEDLE BIOPSY SPINAL No

CORD

62270 SPINAL FLUID TAP No

DIAGNOSTIC

62272 DRAIN CEREBRO SPINAL No

FLUID

62273 INJECT EPIDURAL PATCH No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1050 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62280 TREAT SPINAL CORD No

LESION

62281 TREAT SPINAL CORD Yes InterQual® criteria used. Provide clinical
IQ - Spine
LESION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

62282 TREAT SPINAL CANAL Yes InterQual® criteria used. Provide clinical
IQ - Spine
LESION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

62284 INJECTION FOR No

MYELOGRAM

62287 PERCUTANEOUS Yes* Please review BMCHP criteria for details. Minimally Invasive Treatments for Minimally Invasive
NH-Thermal
DISKECTOMY *Will be covered only when performed in Back Pain Treatments for Back Pain (Eff
Intradiscal the Outpatient setting. 03/01/18)
Surg

62290 INJECT FOR SPINE DISK X- No* *PA req'd if performed as elective proc in
RAY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

62291 INJECT FOR SPINE DISK X- No

RAY

62292 INJECTION INTO DISK No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1051 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62294 INJECTION INTO SPINAL No

ARTERY

62302 MYELOGRAPHY LUMBAR No

INJECTION

62303 MYELOGRAPHY LUMBAR No

INJECTION

62304 MYELOGRAPHY LUMBAR No

INJECTION

62305 MYELOGRAPHY LUMBAR No

INJECTION

62310 INJECT SPINE Yes* InterQual® criteria used. *Will be covered

IQ - Spine
CERV/THORACIC only when performed in the Outpatient
Surgery setting.

62318 INJECT SPINE W/CATH Yes InterQual® criteria used. Provide clinical
IQ - Spine
CRV/THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

62319 INJECT SPINE W/CATH Yes Provide clinical documentation supporting

IQ - Spine
LMB/SCRL rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1052 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62323 NJX INTERLAMINAR Yes InterQual® criteria used. *Will be covered

IQ - Spine
LMBR/SAC only when performed in the Outpatient
Surgery setting.

62350 IMPLANT SPINAL CANAL No* *PA req'd if performed as elective proc in
CATH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

62351 IMPLANT SPINAL CANAL No

CATH

62355 REMOVE SPINAL CANAL No

CATHETER

62360 INSERT SPINE INFUSION No* *PA req'd if performed as elective proc in
DEVICE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

62361 IMPLANT SPINE No

INFUSION PUMP

62362 IMPLANT SPINE No

INFUSION PUMP

62365 REMOVE SPINE INFUSION No

DEVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1053 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

62367 ANALYZE SPINE INFUS No

PUMP

62368 ANALYZE SP INF PUMP No

W/REPROG

62369 ANAL SP INF PMP No

W/REPRG&FILL

62370 ANL SP INF PMP No

W/MDREPRG&FIL

62380 NDSC DCMPRN 1 NTRSPC Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
LUMBAR more details Back Pain Treatments for Back Pain (Eff
03/01/18)

62380 NDSC DCMPRN 1 NTRSPC Yes Please review the Well Sense Policy for Private Duty Nursing Services Private Duty Nursing Services
LUMBAR more details (Eff 01/01/19)

63001 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
1/2 CRVL documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63003 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
1/2 THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1054 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63005 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
1/2 LMBR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63011 REMOVE SPINE LAMINA No

1/2 SCRL

63012 REMOVE Yes InterQual® criteria used. Provide clinical

IQ - Spine
LAMINA/FACETS LUMBAR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63015 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
>2 CRVCL documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63016 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
>2 THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63017 REMOVE SPINE LAMINA Yes InterQual® criteria used. Provide clinical
IQ - Spine
>2 LMBR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63020 NECK SPINE DISK Yes* InterQual® criteria used. *Will be covered
IQ - Spine
SURGERY only when performed in the Outpatient
Surgery setting.

63030 LOW BACK DISK SURGERY Yes* InterQual® criteria used. *Will be covered
IQ - Spine
only when performed in the Outpatient
Surgery setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1055 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63035 SPINAL DISK SURGERY No* *PA req'd if performed as elective proc in
ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63040 LAMINOTOMY SINGLE Yes* InterQual® criteria used. *Will be covered

IQ - Spine
CERVICAL only when performed in the Outpatient
Surgery setting.

63042 LAMINOTOMY SINGLE Yes* InterQual® criteria used. *Will be covered

IQ - Spine
LUMBAR only when performed in the Outpatient
Surgery setting.

63043 LAMINOTOMY ADDL No* *PA req'd if performed as elective proc in

CERVICAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63044 LAMINOTOMY ADDL No* *PA req'd if performed as elective proc in

LUMBAR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63045 REMOVE SPINE LAMINA 1 Yes* InterQual® criteria used. *Will be covered
IQ - Spine
CRVL only when performed in the Outpatient
Surgery setting.

63046 REMOVE SPINE LAMINA 1 Yes InterQual® criteria used. Provide clinical
IQ - Spine
THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63047 REMOVE SPINE LAMINA 1 Yes* InterQual® criteria used. *Will be covered
IQ - Spine
LMBR only when performed in the Outpatient
Surgery setting.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1056 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63048 REMOVE SPINAL LAMINA No* *PA req'd if performed as elective proc in
ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63050 CERVICAL LAMINOPLSTY Yes InterQual® criteria used. Provide clinical

IQ - Spine
2/> SEG documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63051 C-LAMINOPLASTY Yes InterQual® criteria used. Provide clinical

IQ - Spine
W/GRAFT/PLATE documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63055 DECOMPRESS SPINAL Yes InterQual® criteria used. Provide clinical

IQ - Spine
CORD THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63056 DECOMPRESS SPINAL Yes* InterQual® criteria used. *Will be covered

IQ - Spine
CORD LMBR only when performed in the Outpatient
Surgery setting.

63057 DECOMPRESS SPINE No* *PA req'd if performed as elective proc in

CORD ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63064 DECOMPRESS SPINAL Yes InterQual® criteria used. Provide clinical

IQ - Spine
CORD THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63066 DECOMPRESS SPINE No

CORD ADD-ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1057 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63075 NECK SPINE DISK Yes* InterQual® criteria used. *Will be covered
IQ - Spine
SURGERY only when performed in the Outpatient
Surgery setting.

63076 NECK SPINE DISK No* *PA req'd if performed as elective proc in
SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

63077 SPINE DISK SURGERY Yes InterQual® criteria used. Provide clinical
IQ - Spine
THORAX documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63078 SPINE DISK SURGERY No

THORAX

63081 REMOVE VERT BODY Yes InterQual® criteria used. Provide clinical
IQ - Spine
DCMPRN CRVL documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63082 REMOVE VERTEBRAL No

BODY ADD-ON

63085 REMOVE VERT BODY Yes InterQual® criteria used. Provide clinical
IQ - Spine
DCMPRN THRC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63086 REMOVE VERTEBRAL No

BODY ADD-ON

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1058 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63087 REMOV VERTBR DCMPRN Yes InterQual® criteria used. Provide clinical
IQ - Spine
THRCLMBR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63088 REMOVE VERTEBRAL No

BODY ADD-ON

63090 REMOVE VERT BODY Yes InterQual® criteria used. Provide clinical
IQ - Spine
DCMPRN LMBR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

63091 REMOVE VERTEBRAL No

BODY ADD-ON

63101 REMOVE VERT BODY No

DCMPRN THRC

63102 REMOVE VERT BODY No

DCMPRN LMBR

63103 REMOVE VERTEBRAL No

BODY ADD-ON

63170 INCISE SPINAL CORD No

TRACT(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1059 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63172 DRAINAGE OF SPINAL No

CYST

63173 DRAINAGE OF SPINAL No

CYST

63180 REVISE SPINAL CORD No

LIGAMENTS

63182 REVISE SPINAL CORD No

LIGAMENTS

63185 INCISE SPINE NRV HALF No

SEGMNT

63190 INCISE SPINE NRV >2 No

SEGMNTS

63191 INCISE SPINE ACCESSORY No

NERVE

63194 INCISE SPINE & CORD No

CERVICAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1060 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63195 INCISE SPINE & CORD No

THORACIC

63196 INCISE SPINE&CORD 2 No

TRX CRVL

63197 INCISE SPINE&CORD 2 No

TRX THRC

63198 INCISE SPIN&CORD 2 No

STGS CRVL

63199 INCISE SPIN&CORD 2 No

STGS THRC

63200 RELEASE SPINAL CORD No

LUMBAR

63250 REVISE SPINAL CORD No

VSLS CRVL

63251 REVISE SPINAL CORD No

VSLS THRC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1061 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63252 REVISE SPINE CORD VSL No

THRLMB

63265 EXCISE INTRASPINL No

LESION CRV

63266 EXCISE INTRSPINL LESION No

THRC

63267 EXCISE INTRSPINL LESION No

LMBR

63268 EXCISE INTRSPINL LESION No

SCRL

63270 EXCISE INTRSPINL LESION No

CRVL

63271 EXCISE INTRSPINL LESION No

THRC

63272 EXCISE INTRSPINL LESION No

LMBR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1062 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63273 EXCISE INTRSPINL LESION No

SCRL

63275 BX/EXC XDRL SPINE LESN No

CRVL

63276 BX/EXC XDRL SPINE LESN No

THRC

63277 BX/EXC XDRL SPINE LESN No

LMBR

63278 BX/EXC XDRL SPINE LESN No

SCRL

63280 BX/EXC IDRL SPINE LESN No

CRVL

63281 BX/EXC IDRL SPINE LESN No

THRC

63282 BX/EXC IDRL SPINE LESN No

LMBR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1063 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63283 BX/EXC IDRL SPINE LESN No

SCRL

63285 BX/EXC IDRL IMED LESN No

CERVL

63286 BX/EXC IDRL IMED LESN No

THRC

63287 BX/EXC IDRL IMED LESN No

THRLMB

63290 BX/EXC XDRL/IDRL LSN No

ANY LVL

63295 REPAIR LAMINECTOMY No

DEFECT

63300 REMOVE VERT XDRL No

BODY CRVCL

63301 REMOVE VERT XDRL No

BODY THRC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1064 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63302 REMOVE VERT XDRL No

BODY THRLMB

63303 REMOV VERT XDRL BDY No

LMBR/SAC

63304 REMOVE VERT IDRL No

BODY CRVCL

63305 REMOVE VERT IDRL No

BODY THRC

63306 REMOV VERT IDRL BDY No

THRCLMBR

63307 REMOV VERT IDRL BDY No

LMBR/SAC

63308 REMOVE VERTEBRAL No

BODY ADD-ON

63600 REMOVE SPINAL CORD No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1065 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63610 STIMULATION OF SPINAL No

CORD

63615 REMOVE LESION OF No

SPINAL CORD

63620 SRS SPINAL LESION No

63621 SRS SPINAL LESION ADDL No

63650 IMPLANT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Spine
NEUROELECTRODES *Will be covered only when performed in
Surgery the Outpatient setting.

63655 IMPLANT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Spine
NEUROELECTRODES *Will be covered only when performed in
Surgery the Outpatient setting.

63661 REMOVE SPINE ELTRD No Experimental and Investigational Experimental and

PERQ ARAY Treatment Investigational Treatment (Eff
07/01/18)

63662 REMOVE SPINE ELTRD No Experimental and Investigational Experimental and

PLATE Treatment Investigational Treatment (Eff
07/01/18)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1066 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63663 REVISE SPINE ELTRD Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Spine
PERQ ARAY *Will be covered only when performed in
Surgery the Outpatient setting.

63664 REVISE SPINE ELTRD Yes Provide clinical documentation supporting

IQ - Spine
PLATE rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

63685 INSRT/REDO SPINE N Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ - Spine
GENERATOR *Will be covered only when performed in
Surgery the Outpatient setting.

63688 REVISE/REMOVE Yes Provide clinical documentation supporting

IQ - Spine
NEURORECEIVER rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

63700 REPAIR OF SPINAL No

HERNIATION

63702 REPAIR OF SPINAL No

HERNIATION

63704 REPAIR OF SPINAL No

HERNIATION

63706 REPAIR OF SPINAL No

HERNIATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1067 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

63707 REPAIR SPINAL FLUID No

LEAKAGE

63709 REPAIR SPINAL FLUID No

LEAKAGE

63710 GRAFT REPAIR OF SPINE No

DEFECT

63740 INSTALL SPINAL SHUNT No

63741 INSTALL SPINAL SHUNT No

63744 REVISION OF SPINAL No

SHUNT

63746 REMOVAL OF SPINAL No

SHUNT

64400 N BLOCK INJ TRIGEMINAL No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1068 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64402 N BLOCK INJ FACIAL No

64405 N BLOCK INJ OCCIPITAL No

64408 N BLOCK INJ VAGUS No

64410 N BLOCK INJ PHRENIC No

64413 N BLOCK INJ CERVICAL No

PLEXUS

64415 N BLOCK INJ BRACHIAL No

PLEXUS

64416 N BLOCK CONT INFUSE B No

PLEX

64417 N BLOCK INJ AXILLARY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1069 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64418 N BLOCK INJ No

SUPRASCAPULAR

64420 N BLOCK INJ INTERCOST No

SNG

64421 N BLOCK INJ INTERCOST No

MLT

64425 N BLOCK INJ ILIO- No

ING/HYPOGI

64430 N BLOCK INJ PUDENDAL No

64435 N BLOCK INJ No

PARACERVICAL

64445 N BLOCK INJ SCIATIC SNG No

64446 N BLK INJ SCIATIC CONT No

INF

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1070 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64447 N BLOCK INJ FEM SINGLE No

64448 N BLOCK INJ FEM CONT No

INF

64449 N BLOCK INJ LUMBAR No

PLEXUS

64450 N BLOCK OTHER No

PERIPHERAL

64455 N BLOCK INJ PLANTAR No

DIGIT

64461 PVB THORACIC SINGLE No

INJ SITE

64462 PVB THORACIC 2ND+ INJ No

SITE

64463 PVB THORACIC CONT No

INFUSION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1071 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64479 INJ FORAMEN EPIDURAL Yes* InterQual® criteria used. *Will be covered
IQ - Spine
C/T only when performed in the Outpatient
Surgery setting.

64480 INJ FORAMEN EPIDURAL No* *PA req'd if performed as elective proc in
ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64483 INJ FORAMEN EPIDURAL Yes* InterQual® criteria used. *Will be covered
IQ - Spine
L/S only when performed in the Outpatient
Surgery setting.

64484 INJ FORAMEN EPIDURAL No* *PA req'd if performed as elective proc in
ADD-ON the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64486 TAP BLOCK UNIL BY No

INJECTION

64487 TAP BLOCK UNI BY No

INFUSION

64488 TAP BLOCK BI INJECTION No

64489 TAP BLOCK BI BY No

INFUSION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1072 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64490 INJ PARAVERT F JNT C/T 1 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64491 INJ PARAVERT F JNT C/T 2 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64492 INJ PARAVERT F JNT C/T 3 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64493 INJ PARAVERT F JNT L/S 1 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64494 INJ PARAVERT F JNT L/S 2 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64495 INJ PARAVERT F JNT L/S 3 Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LEV *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

64505 N BLOCK No* *PA req'd if performed as elective proc in

SPENOPALATINE GANGL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64508 N BLOCK CAROTID SINUS No* *PA req'd if performed as elective proc in
S/P the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1073 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64510 N BLOCK STELLATE No* *PA req'd if performed as elective proc in

GANGLION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64517 N BLOCK INJ HYPOGAS No* *PA req'd if performed as elective proc in
PLXS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64520 N BLOCK No* *PA req'd if performed as elective proc in

LUMBAR/THORACIC the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64530 N BLOCK INJ CELIAC No* *PA req'd if performed as elective proc in
PELUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64550 APPLY Yes AUTH REQ IS DX SPECIFIC-SEE POLICY

NEUROSTIMULATOR

64555 IMPLANT Yes Please review the Well Sense Policy for Occipital Nerve Stimulation Occipital Nerve Stimulation (
NH-Occipital
NEUROELECTRODES more details Eff 03/01/18)
Nerve Stim

64561 IMPLANT Yes Please review the Well Sense Policy for Sacral Nerve Stimulation for Sacral Nerve Stimulation for
NH-Sacral
NEUROELECTRODES more details Incontinence and Urinary Conditions Incontinence and Urinary
Nerve Stim Conditions ( Eff 01/01/19)

64565 IMPLANT No
NEUROELECTRODES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1074 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64566 NEUROELTRD STIM POST Yes Please review the Well Sense Policy for Posterior Tibial Nerve Stimulation Posterior Tibial Nerve Posterior Tibial Nerve
NH-Post Tibial
TIBIAL more details Stimulation (Eff 01/01/19 and Stimulation (Eff
Nerve Stim Retired 02/28/19) 03/01/19)

64570 REMOVE VAGUS N ELTRD No

64575 IMPLANT Yes* Please review BMCHP criteria for details. Occipital Nerve Stimulation Occipital Nerve Stimulation (
NH_Occipital
NEUROELECTRODES *Will be covered only when performed in Eff 03/01/18)
Nerve Stim the Outpatient setting.

64580 IMPLANT No
NEUROELECTRODES

64581 IMPLANT Yes Please review the Well Sense Policy for Sacral Nerve Stimulation for Sacral Nerve Stimulation for
NH-Sacral
NEUROELECTRODES more details Incontinence and Urinary Conditions Incontinence and Urinary
Nerve Stim Conditions ( Eff 01/01/19)

64585 REVISE/REMOVE Yes Please review the Well Sense Policy for Occipital Nerve Stimulation Occipital Nerve Stimulation (
NH-Sacral OR
NEUROELECTRODE more details Eff 03/01/18)
Occipital Nerv
Stim

64585 REVISE/REMOVE Yes Please review the Well Sense Policy for Sacral Nerve Stimulation for Sacral Nerve Stimulation for
NH-Sacral OR
NEUROELECTRODE more details Incontinence and Urinary Conditions Incontinence and Urinary
Occipital Nerv Conditions ( Eff 01/01/19)
Stim

64590 INSRT/REDO PN/GASTR Yes Depending on service, criteria is provided Sacral Nerve Stimulation for Sacral Nerve Stimulation for
IQ - GI Surgery
STIMUL in the Well Sense Policy OR InterQual® - GI Incontinence and Urinary Conditions Incontinence and Urinary
OR NH-Sacral Surgery Conditions ( Eff 01/01/19)
OR Occipital
Nerv

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1075 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64590 INSRT/REDO PN/GASTR Yes Depending on service, criteria is provided Occipital Nerve Stimulation Occipital Nerve Stimulation (
IQ - GI Surgery
STIMUL in the Well Sense Policy OR InterQual® - GI Eff 03/01/18)
OR NH-Sacral Surgery
OR Occipital
Nerv

64595 REVISE/RMV PN/GASTR Yes Depending on service, criteria is provided Sacral Nerve Stimulation for Sacral Nerve Stimulation for
IQ - GI Surgery
STIMUL in the Well Sense Policy OR InterQual® - GI Incontinence and Urinary Conditions Incontinence and Urinary
OR NH-Sacral Surgery Conditions ( Eff 01/01/19)
OR Occipital
Nerv

64595 REVISE/RMV PN/GASTR Yes Depending on service, criteria is provided Occipital Nerve Stimulation Occipital Nerve Stimulation (
IQ - GI Surgery
STIMUL in the Well Sense Policy OR InterQual® - GI Eff 03/01/18)
OR NH-Sacral Surgery
OR Occipital
Nerv

64600 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-
OF NERVE *Will be covered only when performed in
Experimental/I the Outpatient setting.
nvestigation

64605 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-
OF NERVE *Will be covered only when performed in
Experimental/I the Outpatient setting.
nvestigation

64610 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-
OF NERVE *Will be covered only when performed in
Experimental/I the Outpatient setting.
nvestigation

64611 CHEMODENERV SALIV No

GLANDS

64612 DESTROY NERVE FACE No

MUSCLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1076 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64615 CHEMODENERV MUSC No

MIGRAINE

64616 CHEMODENERV MUSC No

NECK DYSTON

64617 CHEMODENER MUSCLE No

LARYNX EMG

64620 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-
OF NERVE *Will be covered only when performed in
Experimental/I the Outpatient setting.
nvestigation

64630 INJECTION TREATMENT No* *PA req'd if performed as elective proc in

OF NERVE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64632 N BLOCK INJ COMMON No* *PA req'd if performed as elective proc in
DIGIT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64633 DESTROY CERV/THOR Yes* Please review BMCHP criteria for details. Denervation of Facet Joints or Denervation of Facet Joints or
NH-
FACET JNT *Will be covered only when performed in Sacroiliac Joint Sacroiliac Joints (Eff
Radiofrequenc the Outpatient setting. 05/01/18)
y Facet Denerv

64634 DESTROY C/TH FACET JNT Yes* Please review BMCHP criteria for details. Denervation of Facet Joints or Denervation of Facet Joints or
NH-
ADDL *Will be covered only when performed in Sacroiliac Joint Sacroiliac Joints (Eff
Radiofrequenc the Outpatient setting. 05/01/18)
y Facet Denerv

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1077 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64635 DESTROY LUMB/SAC Yes* Please review BMCHP criteria for details. Denervation of Facet Joints or Denervation of Facet Joints or
NH-
FACET JNT *Will be covered only when performed in Sacroiliac Joint Sacroiliac Joints (Eff
Radiofrequenc the Outpatient setting. 05/01/18)
y Facet Denerv

64636 DESTROY L/S FACET JNT Yes* Please review BMCHP criteria for details. Denervation of Facet Joints or Denervation of Facet Joints or
NH-
ADDL *Will be covered only when performed in Sacroiliac Joint Sacroiliac Joints (Eff
Radiofrequenc the Outpatient setting. 05/01/18)
y Facet Denerv

64640 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-IQ -
OF NERVE *Will be covered only when performed in
Liga/Tend/Ner the Outpatient setting.
ve Surg

64642 CHEMODENERV 1 No
EXTREMITY 1-4

64643 CHEMODENERV 1 No
EXTREM 1-4 EA

64644 CHEMODENERV 1 No
EXTREM 5/> MUS

64645 CHEMODENERV 1 No
EXTREM 5/> EA

64646 CHEMODENERV TRUNK No

MUSC 1-5

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1078 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64647 CHEMODENERV TRUNK No

MUSC 6/>

64650 CHEMODENERV ECCRINE Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
GLANDS more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

64653 CHEMODENERV ECCRINE Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
GLANDS more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

64680 INJECTION TREATMENT Yes* Please review BMCHP criteria for details. InterQual® criteria is available
NH-
OF NERVE *Will be covered only when performed in
Experimental/I the Outpatient setting.
nvestigation

64681 INJECTION TREATMENT No* *PA req'd if performed as elective proc in

OF NERVE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64702 REVISE FINGER/TOE No

NERVE

64704 REVISE HAND/FOOT No

NERVE

64708 REVISE ARM/LEG NERVE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1079 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64712 REVISION OF SCIATIC No

NERVE

64713 REVISION OF ARM No

NERVE(S)

64714 REVISE LOW BACK No

NERVE(S)

64716 REVISION OF CRANIAL No

NERVE

64718 REVISE ULNAR NERVE AT No* *PA req'd if performed as elective proc in
ELBOW the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64719 REVISE ULNAR NERVE AT No* *PA req'd if performed as elective proc in
WRIST the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64721 CARPAL TUNNEL No* *PA req'd if performed as elective proc in

SURGERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64722 RELIEVE PRESSURE ON No

NERVE(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1080 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64726 RELEASE FOOT/TOE No

NERVE

64727 INTERNAL NERVE No

REVISION

64732 INCISION OF BROW No

NERVE

64734 INCISION OF CHEEK No

NERVE

64736 INCISION OF CHIN NERVE No

64738 INCISION OF JAW NERVE No

64740 INCISION OF TONGUE No

NERVE

64742 INCISION OF FACIAL No

NERVE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1081 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64744 INCISE NERVE BACK OF No

HEAD

64746 INCISE DIAPHRAGM No

NERVE

64755 INCISION OF STOMACH No

NERVES

64760 INCISION OF VAGUS No

NERVE

64763 INCISE HIP/THIGH NERVE No

64766 INCISE HIP/THIGH NERVE No

64771 SEVER CRANIAL NERVE No

64772 INCISION OF SPINAL No

NERVE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1082 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64774 REMOVE SKIN NERVE No

LESION

64776 REMOVE DIGIT NERVE No

LESION

64778 DIGIT NERVE SURGERY No

ADD-ON

64782 REMOVE LIMB NERVE No

LESION

64783 LIMB NERVE SURGERY No

ADD-ON

64784 REMOVE NERVE LESION No

64786 REMOVE SCIATIC NERVE No

LESION

64787 IMPLANT NERVE END No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1083 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64788 REMOVE SKIN NERVE No

LESION

64790 REMOVAL OF NERVE No

LESION

64792 REMOVAL OF NERVE No

LESION

64795 BIOPSY OF NERVE No

64802 SYMPATHECTOMY No
CERVICAL

64804 REMOVE SYMPATHETIC No

NERVES

64809 REMOVE SYMPATHETIC No

NERVES

64818 REMOVE SYMPATHETIC No

NERVES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1084 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64820 SYMPATHECTOMY No
DIGITAL ARTERY

64821 REMOVE SYMPATHETIC No

NERVES

64822 REMOVE SYMPATHETIC No

NERVES

64823 SYMPATHECTOMY SUPFC No

PALMAR

64831 REPAIR OF DIGIT NERVE Yes* InterQual® criteria used. *Will be covered
IQ - Ligament
only when performed in the Outpatient
tendon nerve setting.
Surgery

64832 REPAIR NERVE ADD-ON No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64834 REPAIR OF HAND OR Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
FOOT NERVE only when performed in the Outpatient
tendon nerve setting.
Surgery

64835 REPAIR OF HAND OR Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
FOOT NERVE only when performed in the Outpatient
tendon nerve setting.
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1085 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64836 REPAIR OF HAND OR Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
FOOT NERVE only when performed in the Outpatient
tendon nerve setting.
Surgery

64837 REPAIR NERVE ADD-ON No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64840 REPAIR OF LEG NERVE No

64856 REPAIR/TRANSPOSE Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
NERVE only when performed in the Outpatient
tendon nerve setting.
Surgery

64857 REPAIR ARM/LEG NERVE No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64858 REPAIR SCIATIC NERVE No

64859 NERVE SURGERY No

64861 REPAIR OF ARM NERVES No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1086 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64862 REPAIR OF LOW BACK No

NERVES

64864 REPAIR OF FACIAL NERVE No

64865 REPAIR OF FACIAL NERVE No

64866 FUSION OF No
FACIAL/OTHER NERVE

64868 FUSION OF No
FACIAL/OTHER NERVE

64872 SUBSEQUENT REPAIR OF No

NERVE

64874 REPAIR & REVISE NERVE No

ADD-ON

64876 REPAIR NERVE/SHORTEN No

BONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1087 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64885 NERVE GRAFT No

HEAD/NECK </4 CM

64886 NERVE GRAFT No

HEAD/NECK >4 CM

64890 NERVE GRAFT Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
HAND/FOOT </4 CM only when performed in the Outpatient
tendon nerve setting.
Surgery

64891 NERVE GRAFT Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
HAND/FOOT >4 CM only when performed in the Outpatient
tendon nerve setting.
Surgery

64892 NERVE GRAFT ARM/LEG No

<4 CM

64893 NERVE GRAFT ARM/LEG No

>4 CM

64895 NERVE GRAFT Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
HAND/FOOT </4 CM only when performed in the Outpatient
tendon nerve setting.
Surgery

64896 NERVE GRAFT Yes* InterQual® criteria used. *Will be covered

IQ - Ligament
HAND/FOOT >4 CM only when performed in the Outpatient
tendon nerve setting.
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1088 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64897 NERVE GRAFT ARM/LEG No

</4 CM

64898 NERVE GRAFT ARM/LEG No

>4 CM

64901 NERVE GRAFT ADD-ON No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64902 NERVE GRAFT ADD-ON No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

64905 NERVE PEDICLE TRANSFER No

64907 NERVE PEDICLE TRANSFER No

64910 NERVE REPAIR Yes Please review the Well Sense Policy for Nerve Repairs for Peripheral Nerve Nerve Repairs for Peripheral
NH-Nerve
W/ALLOGRAFT more details Injuries Using Allografts, Autografts, Nerve Injuries Using
Repairs/Periph and Conduits Allografts, Autografts, and
Injury
Conduits (Eff 02/01/19)

64911 NEURORRAPHY W/VEIN Yes Please review the Well Sense Policy for Nerve Repairs for Peripheral Nerve Nerve Repairs for Peripheral
NH-Nerve
AUTOGRAFT more details Injuries Using Allografts, Autografts, Nerve Injuries Using
Repairs/Periph and Conduits Allografts, Autografts, and
Injury
Conduits (Eff 02/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1089 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

64912 NRV RPR W/NRV ALGRFT Yes

1ST

64913 NRV RPR W/NRV ALGRFT Yes Please review the Well Sense Policy for
EA ADDL more details

64999 NERVOUS SYSTEM No

SURGERY

operating microscope
69990 MICROSURGERY ADD-ON No

reproductive system and intersex

55920 PLACE NEEDLES PELVIC No
FOR RT

55970 SEX TRANSFORMATION Yes

M TO F

55980 SEX TRANSFORMATION F Yes

TO M

respiratory system

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1090 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30000 DRAINAGE OF NOSE No

LESION

30020 DRAINAGE OF NOSE No

LESION

30100 INTRANASAL BIOPSY No

30110 REMOVAL OF NOSE Yes* InterQual® criteria used. *Will be covered

NH-IQ - ENT
POLYP(S) only when performed in the Outpatient
Surg setting.

30115 REMOVAL OF NOSE No* *PA req'd if performed as elective proc in

POLYP(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

30117 REMOVAL OF No
INTRANASAL LESION

30118 REMOVAL OF No
INTRANASAL LESION

30120 REVISION OF NOSE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1091 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30124 REMOVAL OF NOSE No

LESION

30125 REMOVAL OF NOSE No

LESION

30130 EXCISE INFERIOR Yes* InterQual® criteria used. *Will be covered

NH-IQ - ENT
TURBINATE only when performed in the Outpatient
Surg setting.

30140 RESECT INFERIOR Yes* InterQual® criteria used. *Will be covered

NH-IQ - ENT
TURBINATE only when performed in the Outpatient
Surg setting.

30150 PARTIAL REMOVAL OF No

NOSE

30160 REMOVAL OF NOSE No

30200 INJECTION TREATMENT No

OF NOSE

30210 NASAL SINUS THERAPY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1092 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30220 INSERT NASAL SEPTAL No

BUTTON

30300 REMOVE NASAL FOREIGN No

BODY

30310 REMOVE NASAL FOREIGN No

BODY

30320 REMOVE NASAL FOREIGN No

BODY

30400 RECONSTRUCTION OF Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
NOSE *Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

30410 RECONSTRUCTION OF Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
NOSE *Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

30420 RECONSTRUCTION OF Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
NOSE *Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

30430 REVISION OF NOSE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1093 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30435 REVISION OF NOSE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

30450 REVISION OF NOSE Yes* Please review BMCHP criteria for details. InterQual® criteria is available
IQ -
*Will be covered only when performed in
Potentially the Outpatient setting.
Cosmetic
Surgery

30460 REVISION OF NOSE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30462 REVISION OF NOSE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30465 REPAIR NASAL STENOSIS Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30520 REPAIR OF NASAL Yes* Please review BMCHP criteria for details. Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
NH-IQ - ENT
SEPTUM *Will be covered only when performed in Restorative Services and Restorative Services (Eff
Surg the Outpatient setting. 07/01/18)

30540 REPAIR NASAL DEFECT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30545 REPAIR NASAL DEFECT Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1094 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30560 RELEASE OF NASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
ADHESIONS more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30580 REPAIR UPPER JAW Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
FISTULA more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30600 REPAIR MOUTH/NOSE Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
IQ -
FISTULA more details Restorative Services and Restorative Services (Eff
Potentially 07/01/18)
cosmetic

30620 INTRANASAL Yes Please review the Well Sense Policy for Cosmetic, Reconstructive, and Cosmetic, Reconstructive,
NH-IQ - ENT
RECONSTRUCTION more details Restorative Services and Restorative Services (Eff
Surg 07/01/18)

30630 REPAIR NASAL SEPTUM Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
NH-IQ - ENT
DEFECT more details 11/01/18)
Surg

30801 ABLATE INF TURBINATE No

SUPERF

30802 ABLATE INF TURBINATE No

SUBMUC

30901 CONTROL OF NOSEBLEED No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1095 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

30903 CONTROL OF NOSEBLEED No

30905 CONTROL OF NOSEBLEED No

30906 REPEAT CONTROL OF No

NOSEBLEED

30915 LIGATION NASAL SINUS No

ARTERY

30920 LIGATION UPPER JAW No* *PA req'd if performed as elective proc in
ARTERY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

30930 THER FX NASAL INF No

TURBINATE

30999 NASAL SURGERY No

PROCEDURE

31000 IRRIGATION MAXILLARY No

SINUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1096 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31002 IRRIGATION SPHENOID No

SINUS

31020 EXPLORATION No* *PA req'd if performed as elective proc in

MAXILLARY SINUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31030 EXPLORATION No* *PA req'd if performed as elective proc in

MAXILLARY SINUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31032 EXPLORE SINUS REMOVE No* *PA req'd if performed as elective proc in
POLYPS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31040 EXPLORATION BEHIND No

UPPER JAW

31050 EXPLORATION SPHENOID No

SINUS

31051 SPHENOID SINUS No

SURGERY

31070 EXPLORATION OF No
FRONTAL SINUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1097 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31075 EXPLORATION OF No
FRONTAL SINUS

31080 REMOVAL OF FRONTAL No

SINUS

31081 REMOVAL OF FRONTAL No

SINUS

31084 REMOVAL OF FRONTAL No

SINUS

31085 REMOVAL OF FRONTAL No

SINUS

31086 REMOVAL OF FRONTAL No

SINUS

31087 REMOVAL OF FRONTAL No

SINUS

31090 EXPLORATION OF No
SINUSES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1098 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31200 REMOVAL OF ETHMOID No

SINUS

31201 REMOVAL OF ETHMOID No

SINUS

31205 REMOVAL OF ETHMOID No

SINUS

31225 REMOVAL OF UPPER JAW No

31230 REMOVAL OF UPPER JAW No

31231 NASAL ENDOSCOPY DX No

31233 NASAL/SINUS No
ENDOSCOPY DX

31235 NASAL/SINUS No
ENDOSCOPY DX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1099 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31237 NASAL/SINUS No* *PA req'd if performed as elective proc in

ENDOSCOPY SURG the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31238 NASAL/SINUS No
ENDOSCOPY SURG

31239 NASAL/SINUS No
ENDOSCOPY SURG

31240 NASAL/SINUS No
ENDOSCOPY SURG

31254 REVISION OF ETHMOID No

SINUS

31255 REMOVAL OF ETHMOID No

SINUS

31256 EXPLORATION No* *PA req'd if performed as elective proc in

MAXILLARY SINUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31267 ENDOSCOPY MAXILLARY No* *PA req'd if performed as elective proc in

SINUS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1100 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31276 SINUS ENDOSCOPY No

SURGICAL

31287 NASAL/SINUS No
ENDOSCOPY SURG

31288 NASAL/SINUS No
ENDOSCOPY SURG

31290 NASAL/SINUS No
ENDOSCOPY SURG

31291 NASAL/SINUS No
ENDOSCOPY SURG

31292 NASAL/SINUS No
ENDOSCOPY SURG

31293 NASAL/SINUS No
ENDOSCOPY SURG

31294 NASAL/SINUS No
ENDOSCOPY SURG

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1101 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31295 SINUS ENDO Yes Please review the Well Sense Policy for Balloon Sinus Ostial Dilation Balloon Sinus Ostial Dilation (
NH-Balloon
W/BALLOON DIL more details Eff 12/01/18)
Ostial Dilation

31296 SINUS ENDO Yes Please review the Well Sense Policy for Balloon Sinus Ostial Dilation Balloon Sinus Ostial Dilation (
NH-Balloon
W/BALLOON DIL more details Eff 12/01/18)
Ostial Dilation

31297 SINUS ENDO Yes Please review the Well Sense Policy for Balloon Sinus Ostial Dilation Balloon Sinus Ostial Dilation (
NH-Balloon
W/BALLOON DIL more details Eff 12/01/18)
Ostial Dilation

31298 SINUS ENDO Yes Please review the Well Sense Policy for Balloon Sinus Ostial Dilation Balloon Sinus Ostial Dilation (
NH-Balloon
W/BALLOON DIL more details Eff 12/01/18)
Ostial Dilation

31299 SINUS SURGERY No

PROCEDURE

31300 REMOVAL OF LARYNX No

LESION

31320 DIAGNOSTIC INCISION No

LARYNX

31360 REMOVAL OF LARYNX No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1102 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31365 REMOVAL OF LARYNX No

31367 PARTIAL REMOVAL OF No

LARYNX

31368 PARTIAL REMOVAL OF No

LARYNX

31370 PARTIAL REMOVAL OF No

LARYNX

31375 PARTIAL REMOVAL OF No

LARYNX

31380 PARTIAL REMOVAL OF No

LARYNX

31382 PARTIAL REMOVAL OF No

LARYNX

31390 REMOVAL OF LARYNX & No

PHARYNX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1103 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31395 RECONSTRUCT LARYNX & No

PHARYNX

31400 REVISION OF LARYNX No

31420 REMOVAL OF EPIGLOTTIS No

31500 INSERT EMERGENCY No

AIRWAY

31502 CHANGE OF WINDPIPE No

AIRWAY

31505 DIAGNOSTIC No
LARYNGOSCOPY

31510 LARYNGOSCOPY WITH No

BIOPSY

31511 REMOVE FOREIGN BODY No

LARYNX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1104 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31512 REMOVAL OF LARYNX No

LESION

31513 INJECTION INTO VOCAL No

CORD

31515 LARYNGOSCOPY FOR No

ASPIRATION

31520 DX LARYNGOSCOPY No
NEWBORN

31525 DX LARYNGOSCOPY EXCL No

NB

31526 DX LARYNGOSCOPY No
W/OPER SCOPE

31527 LARYNGOSCOPY FOR No

TREATMENT

31528 LARYNGOSCOPY AND No

DILATION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1105 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31529 LARYNGOSCOPY AND No

DILATION

31530 LARYNGOSCOPY W/FB No

REMOVAL

31531 LARYNGOSCOPY W/FB & No

OP SCOPE

31535 LARYNGOSCOPY No
W/BIOPSY

31536 LARYNGOSCOPY W/BX & No

OP SCOPE

31540 LARYNGOSCOPY W/EXC No

OF TUMOR

31541 LARYNSCOP W/TUMR No

EXC + SCOPE

31545 REMOVE VC LESION No

W/SCOPE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1106 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31546 REMOVE VC LESION No

SCOPE/GRAFT

31560 LARYNGOSCOP No
W/ARYTENOIDECTOM

31561 LARYNSCOP REMVE CART No

+ SCOP

31570 LARYNGOSCOPE W/VC INJ No

31571 LARYNGOSCOP W/VC INJ No

+ SCOPE

31575 DIAGNOSTIC No
LARYNGOSCOPY

31576 LARYNGOSCOPY WITH No

BIOPSY

31577 LARGSC W/RMVL No

FOREIGN BDY(S)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1107 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31578 LARGSC W/REMOVAL No

LESION

31579 LARYNGOSCOPY No
TELESCOPIC

31580 LARYNGOPLASTY No
LARYNGEAL WEB

31582 REVISION OF LARYNX No

31584 LARYNGOPLASTY FX No
RDCTJ FIXJ

31587 LARYNGOPLASTY No
CRICOID SPLIT

31588 REVISION OF LARYNX No

31590 REINNERVATE LARYNX No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1108 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31595 LARYNX NERVE SURGERY No

31599 LARYNX SURGERY No

PROCEDURE

31600 INCISION OF WINDPIPE No

31601 INCISION OF WINDPIPE No

31603 INCISION OF WINDPIPE No

31605 INCISION OF WINDPIPE No

31610 INCISION OF WINDPIPE No

31611 SURGERY/SPEECH No
PROSTHESIS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1109 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31612 PUNCTURE/CLEAR No
WINDPIPE

31613 REPAIR WINDPIPE No

OPENING

31614 REPAIR WINDPIPE No

OPENING

31615 VISUALIZATION OF No* *PA req'd if performed as elective proc in

WINDPIPE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31622 DX No* *PA req'd if performed as elective proc in

BRONCHOSCOPE/WASH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31623 DX No* *PA req'd if performed as elective proc in

BRONCHOSCOPE/BRUSH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31624 DX No* *PA req'd if performed as elective proc in

BRONCHOSCOPE/LAVAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31625 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

W/BIOPSY(S) the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1110 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31626 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

W/MARKERS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31627 NAVIGATIONAL No
BRONCHOSCOPY

31628 BRONCHOSCOPY/LUNG No* *PA req'd if performed as elective proc in

BX EACH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31629 BRONCHOSCOPY/NEEDLE No* *PA req'd if performed as elective proc in

BX EACH the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31630 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

DILATE/FX REPR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31631 BRONCHOSCOPY DILATE No* *PA req'd if performed as elective proc in

W/STENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31632 BRONCHOSCOPY/LUNG No
BX ADDL

31633 BRONCHOSCOPY/NEEDLE No
BX ADDL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1111 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31634 BRONCH W/BALLOON No* *PA req'd if performed as elective proc in

OCCLUSION the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31635 BRONCHOSCOPY W/FB No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31636 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

BRONCH STENTS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31637 BRONCHOSCOPY STENT No

ADD-ON

31638 BRONCHOSCOPY REVISE No* *PA req'd if performed as elective proc in

STENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31640 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

W/TUMOR EXCISE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31641 BRONCHOSCOPY TREAT No* *PA req'd if performed as elective proc in

BLOCKAGE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31643 DIAG No* *PA req'd if performed as elective proc in

BRONCHOSCOPE/CATHET the Inpatient setting; incl all clinical
ER documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1112 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31645 BRONCHOSCOPY CLEAR No* *PA req'd if performed as elective proc in

AIRWAYS the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31646 BRONCHOSCOPY No* *PA req'd if performed as elective proc in

RECLEAR AIRWAY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

31647 BRONCHIAL VALVE INIT No

INSERT

31648 BRONCHIAL VALVE No

REMOV INIT

31649 BRONCHIAL VALVE No

REMOV ADDL

31651 BRONCHIAL VALVE ADDL No

INSERT

31652 BRONCH EBUS SAMPLNG No

1/2 NODE

31653 BRONCH EBUS SAMPLNG No

3/> NODE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1113 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31654 BRONCH EBUS IVNTJ No

PERPH LES

31660 BRONCH THERMOPLSTY No

1 LOBE

31661 BRONCH THERMOPLSTY No

2/> LOBES

31717 BRONCHIAL BRUSH No

BIOPSY

31720 CLEARANCE OF AIRWAYS No

31725 CLEARANCE OF AIRWAYS No

31730 INTRO WINDPIPE No

WIRE/TUBE

31750 REPAIR OF WINDPIPE No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1114 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31755 REPAIR OF WINDPIPE No

31760 REPAIR OF WINDPIPE No

31766 RECONSTRUCTION OF No
WINDPIPE

31770 REPAIR/GRAFT OF No
BRONCHUS

31775 RECONSTRUCT No
BRONCHUS

31780 RECONSTRUCT WINDPIPE No

31781 RECONSTRUCT WINDPIPE No

31785 REMOVE WINDPIPE No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1115 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

31786 REMOVE WINDPIPE No

LESION

31800 REPAIR OF WINDPIPE No

INJURY

31805 REPAIR OF WINDPIPE No

INJURY

31820 CLOSURE OF WINDPIPE No

LESION

31825 REPAIR OF WINDPIPE No

DEFECT

31830 REVISE WINDPIPE SCAR No

31899 AIRWAYS SURGICAL No

PROCEDURE

32035 THORACOSTOMY W/RIB No

RESECTION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1116 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32036 THORACOSTOMY No
W/FLAP DRAINAGE

32096 OPEN WEDGE/BX LUNG No

INFILTR

32097 OPEN WEDGE/BX LUNG No

NODULE

32098 OPEN BIOPSY OF LUNG No

PLEURA

32100 EXPLORATION OF CHEST No

32110 EXPLORE/REPAIR CHEST No

32120 RE-EXPLORATION OF No
CHEST

32124 EXPLORE CHEST FREE No

ADHESIONS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1117 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32140 REMOVAL OF LUNG No

LESION(S)

32141 REMOVE/TREAT LUNG Yes Provide clinical documentation supporting

IQ - Thoracic
LESIONS rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

32150 REMOVAL OF LUNG No

LESION(S)

32151 REMOVE LUNG FOREIGN No

BODY

32160 OPEN CHEST HEART No

MASSAGE

32200 DRAIN OPEN LUNG No

LESION

32215 TREAT CHEST LINING Yes Provide clinical documentation supporting

IQ - Thoracic
rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

32220 RELEASE OF LUNG Yes Provide clinical documentation supporting

IQ - Thoracic
rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1118 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32225 PARTIAL RELEASE OF Yes Provide clinical documentation supporting

IQ - Thoracic
LUNG rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

32310 REMOVAL OF CHEST No

LINING

32320 FREE/REMOVE CHEST No

LINING

32400 NEEDLE BIOPSY CHEST No

LINING

32405 PERCUT BX No
LUNG/MEDIASTINUM

32440 REMOVE LUNG No

PNEUMONECTOMY

32442 SLEEVE No
PNEUMONECTOMY

32445 REMOVAL OF LUNG No

EXTRAPLEURAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1119 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32480 PARTIAL REMOVAL OF No

LUNG

32482 BILOBECTOMY No

32484 SEGMENTECTOMY No

32486 SLEEVE LOBECTOMY No

32488 COMPLETION No
PNEUMONECTOMY

32491 LUNG VOLUME No

REDUCTION

32501 REPAIR BRONCHUS ADD- No

ON

32503 RESECT APICAL LUNG No

TUMOR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1120 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32504 RESECT APICAL LUNG No

TUM/CHEST

32505 WEDGE RESECT OF LUNG No

INITIAL

32506 WEDGE RESECT OF LUNG No

ADD-ON

32507 WEDGE RESECT OF LUNG No

DIAG

32540 REMOVAL OF LUNG No

LESION

32550 INSERT PLEURAL CATH No

32551 INSERTION OF CHEST No

TUBE

32552 REMOVE LUNG CATHETER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1121 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32553 INS MARK THOR FOR RT No

PERQ

32554 ASPIRATE PLEURA W/O No

IMAGING

32555 ASPIRATE PLEURA W/ No

IMAGING

32556 INSERT CATH PLEURA No

W/O IMAGE

32557 INSERT CATH PLEURA W/ No

IMAGE

32560 TREAT PLEURODESIS No

W/AGENT

32561 LYSE CHEST FIBRIN INIT No

DAY

32562 LYSE CHEST FIBRIN SUBQ No

DAY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1122 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32601 THORACOSCOPY No
DIAGNOSTIC

32604 THORACOSCOPY WBX SAC No

32606 THORACOSCOPY W/BX No

MED SPACE

32607 THORACOSCOPY W/BX No

INFILTRATE

32608 THORACOSCOPY W/BX No

NODULE

32609 THORACOSCOPY W/BX No

PLEURA

32650 THORACOSCOPY No
W/PLEURODESIS

32651 THORACOSCOPY No
REMOVE CORTEX

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1123 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32652 THORACOSCOPY REM No

TOTL CORTEX

32653 THORACOSCOPY REMOV No

FB/FIBRIN

32654 THORACOSCOPY CONTRL No

BLEEDING

32655 THORACOSCOPY RESECT No

BULLAE

32656 THORACOSCOPY No
W/PLEURECTOMY

32658 THORACOSCOPY W/SAC No

FB REMOVE

32659 THORACOSCOPY W/SAC No

DRAINAGE

32661 THORACOSCOPY No
W/PERICARD EXC

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1124 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32662 THORACOSCOPY No
W/MEDIAST EXC

32663 THORACOSCOPY No
W/LOBECTOMY

32664 THORACOSCOPY W/ TH No
NRV EXC

32665 THORACOSCOP No
W/ESOPH MUSC EXC

32666 THORACOSCOPY No
W/WEDGE RESECT

32667 THORACOSCOPY W/W No

RESECT ADDL

32668 THORACOSCOPY W/W No

RESECT DIAG

32669 THORACOSCOPY No
REMOVE SEGMENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1125 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32670 THORACOSCOPY No
BILOBECTOMY

32671 THORACOSCOPY No
PNEUMONECTOMY

32672 THORACOSCOPY FOR No

LVRS

32673 THORACOSCOPY No
W/THYMUS RESECT

32674 THORACOSCOPY LYMPH No

NODE EXC

32701 THORAX STEREO RAD No

TARGETW/TX

32800 REPAIR LUNG HERNIA No

32810 CLOSE CHEST AFTER No

DRAINAGE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1126 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32815 CLOSE BRONCHIAL No

FISTULA

32820 RECONSTRUCT INJURED No

CHEST

32850 DONOR No
PNEUMONECTOMY

32851 LUNG TRANSPLANT Yes Please review the Well Sense Policy for Transplantation of Lung or Lobar Transplantation of Lung or
NH-Transplant
SINGLE more details Lung Lobar Lung (Eff 04/01/18)
Lung

32852 LUNG TRANSPLANT WITH Yes Please review the Well Sense Policy for Transplantation of Lung or Lobar Transplantation of Lung or
NH-Transplant
BYPASS more details Lung Lobar Lung (Eff 04/01/18)
Lung

32853 LUNG TRANSPLANT Yes Please review the Well Sense Policy for Transplantation of Lung or Lobar Transplantation of Lung or
NH-Transplant
DOUBLE more details Lung Lobar Lung (Eff 04/01/18)
Lung

32854 LUNG TRANSPLANT WITH Yes Please review the Well Sense Policy for Transplantation of Lung or Lobar Transplantation of Lung or
NH-Transplant
BYPASS more details Lung Lobar Lung (Eff 04/01/18)
Lung

32855 PREPARE DONOR LUNG No

SINGLE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1127 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32856 PREPARE DONOR LUNG No

DOUBLE

32900 REMOVAL OF RIB(S) No

32905 REVISE & REPAIR CHEST No

WALL

32906 REVISE & REPAIR CHEST No

WALL

32940 REVISION OF LUNG No

32960 THERAPEUTIC No
PNEUMOTHORAX

32997 TOTAL LUNG LAVAGE No

32998 PERQ RF ABLATE TX PUL No

TUMOR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1128 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

32999 CHEST SURGERY No

PROCEDURE

urinary system
50010 EXPLORATION OF KIDNEY No

50020 RENAL ABSCESS OPEN No

DRAIN

50040 DRAINAGE OF KIDNEY No

50045 EXPLORATION OF KIDNEY No

50060 REMOVAL OF KIDNEY No

STONE

50065 INCISION OF KIDNEY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1129 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50070 INCISION OF KIDNEY No

50075 REMOVAL OF KIDNEY No

STONE

50080 REMOVAL OF KIDNEY No

STONE

50081 REMOVAL OF KIDNEY No

STONE

50100 REVISE KIDNEY BLOOD No

VESSELS

50120 EXPLORATION OF KIDNEY No

50125 EXPLORE AND DRAIN No

KIDNEY

50130 REMOVAL OF KIDNEY No

STONE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1130 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50135 EXPLORATION OF KIDNEY No

50200 RENAL BIOPSY PERQ No

50205 RENAL BIOPSY OPEN No

50220 REMOVE KIDNEY OPEN No

50225 REMOVAL KIDNEY OPEN No

COMPLEX

50230 REMOVAL KIDNEY OPEN No

RADICAL

50234 REMOVAL OF KIDNEY & No

URETER

50236 REMOVAL OF KIDNEY & No

URETER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1131 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50240 PARTIAL REMOVAL OF No

KIDNEY

50250 CRYOABLATE RENAL No

MASS OPEN

50280 REMOVAL OF KIDNEY No

LESION

50290 REMOVAL OF KIDNEY No

LESION

50300 REMOVE CADAVER No

DONOR KIDNEY

50320 REMOVE KIDNEY LIVING Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
DONOR more details 11/01/18)

50323 PREP CADAVER RENAL No

ALLOGRAFT

50325 PREP DONOR RENAL No

GRAFT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1132 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50327 PREP RENAL No

GRAFT/VENOUS

50328 PREP RENAL No

GRAFT/ARTERIAL

50329 PREP RENAL No

GRAFT/URETERAL

50340 REMOVAL OF KIDNEY Yes Please review the Well Sense Policy for Medically Necessary Medically Necessary ( Eff
more details 11/01/18)

50360 TRANSPLANTATION OF Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ -
KIDNEY more details
Transplant
Surgery

50365 TRANSPLANTATION OF Yes Please review the Well Sense Policy for InterQual® criteria is available
IQ -
KIDNEY more details
Transplant
Surgery

50370 REMOVE TRANSPLANTED No

KIDNEY

50380 REIMPLANTATION OF No
KIDNEY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1133 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50382 CHANGE URETER STENT No

PERCUT

50384 REMOVE URETER STENT No

PERCUT

50385 CHANGE STENT VIA No

TRANSURETH

50386 REMOVE STENT VIA No

TRANSURETH

50387 CHANGE No
NEPHROURETERAL CATH

50389 REMOVE RENAL TUBE No

W/FLUORO

50390 DRAINAGE OF KIDNEY No

LESION

50391 INSTLL RX AGNT INTO No

RNAL TUB

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1134 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50395 CREATE PASSAGE TO No

KIDNEY

50396 MEASURE KIDNEY No

PRESSURE

50400 REVISION OF No
KIDNEY/URETER

50405 REVISION OF No
KIDNEY/URETER

50430 NJX PX NFROSGRM No

&/URTRGRM

50431 NJX PX NFROSGRM No

&/URTRGRM

50432 PLMT NEPHROSTOMY No

CATHETER

50433 PLMT NEPHROURETERAL No

CATHETER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1135 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50434 CONVERT No
NEPHROSTOMY
CATHETER

50435 EXCHANGE No
NEPHROSTOMY CATH

50500 REPAIR OF KIDNEY No

WOUND

50520 CLOSE KIDNEY-SKIN No

FISTULA

50525 CLOSE NEPHROVISCERAL No

FISTULA

50526 REPAIR RENAL-ABDOMEN No

FISTULA

50540 REVISION OF HORSESHOE No

KIDNEY

50541 LAPARO ABLATE RENAL No

CYST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1136 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50542 LAPARO ABLATE RENAL No

MASS

50543 LAPARO PARTIAL No

NEPHRECTOMY

50544 LAPAROSCOPY No
PYELOPLASTY

50545 LAPARO RADICAL No

NEPHRECTOMY

50546 LAPAROSCOPIC No
NEPHRECTOMY

50547 LAPARO REMOVAL No

DONOR KIDNEY

50548 LAPARO REMOVE No

W/URETER

50549 LAPAROSCOPE PROC No

RENAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1137 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50551 KIDNEY ENDOSCOPY No

50553 KIDNEY ENDOSCOPY No

50555 KIDNEY ENDOSCOPY & No

BIOPSY

50557 KIDNEY ENDOSCOPY & No

TREATMENT

50561 KIDNEY ENDOSCOPY & No

TREATMENT

50562 RENAL SCOPE W/TUMOR No

RESECT

50570 KIDNEY ENDOSCOPY No

50572 KIDNEY ENDOSCOPY No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1138 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50574 KIDNEY ENDOSCOPY & No

BIOPSY

50575 KIDNEY ENDOSCOPY No

50576 KIDNEY ENDOSCOPY & No

TREATMENT

50580 KIDNEY ENDOSCOPY & No

TREATMENT

50590 FRAGMENTING OF No* *PA req'd if performed as elective proc in

KIDNEY STONE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

50592 PERC RF ABLATE RENAL No InterQual® criteria is available

TUMOR

50593 PERC CRYO ABLATE No InterQual® criteria is available

RENAL TUM

50600 EXPLORATION OF URETER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1139 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50605 INSERT URETERAL No

SUPPORT

50606 ENDOLUMINAL BX URTR No

RNL PLVS

50610 REMOVAL OF URETER No

STONE

50620 REMOVAL OF URETER No

STONE

50630 REMOVAL OF URETER No

STONE

50650 REMOVAL OF URETER No

50660 REMOVAL OF URETER No

50684 INJECTION FOR URETER X- No

RAY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1140 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50686 MEASURE URETER No

PRESSURE

50688 CHANGE OF URETER No

TUBE/STENT

50690 INJECTION FOR URETER X- No

RAY

50693 PLMT URETERAL STENT No

PRQ

50694 PLMT URETERAL STENT No

PRQ

50695 PLMT URETERAL STENT No

PRQ

50700 REVISION OF URETER No

50705 URETERAL No
EMBOLIZATION/OCCL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1141 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50706 BALLOON DILATE URTRL No

STRIX

50715 RELEASE OF URETER No

50722 RELEASE OF URETER No

50725 RELEASE/REVISE URETER No

50727 REVISE URETER No

50728 REVISE URETER No

50740 FUSION OF URETER & No

KIDNEY

50750 FUSION OF URETER & No

KIDNEY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1142 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50760 FUSION OF URETERS No

50770 SPLICING OF URETERS No

50780 REIMPLANT URETER IN No

BLADDER

50782 REIMPLANT URETER IN No

BLADDER

50783 REIMPLANT URETER IN No

BLADDER

50785 REIMPLANT URETER IN No

BLADDER

50800 IMPLANT URETER IN No

BOWEL

50810 FUSION OF URETER & No

BOWEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1143 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50815 URINE SHUNT TO No

INTESTINE

50820 CONSTRUCT BOWEL No

BLADDER

50825 CONSTRUCT BOWEL No

BLADDER

50830 REVISE URINE FLOW No

50840 REPLACE URETER BY No

BOWEL

50845 APPENDICO- No
VESICOSTOMY

50860 TRANSPLANT URETER TO No

SKIN

50900 REPAIR OF URETER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1144 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50920 CLOSURE URETER/SKIN No

FISTULA

50930 CLOSURE No
URETER/BOWEL FISTULA

50940 RELEASE OF URETER No

50945 LAPAROSCOPY No
URETEROLITHOTOMY

50947 LAPARO NEW No

URETER/BLADDER

50948 LAPARO NEW No

URETER/BLADDER

50949 LAPAROSCOPE PROC No

URETER

50951 ENDOSCOPY OF URETER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1145 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50953 ENDOSCOPY OF URETER No

50955 URETER ENDOSCOPY & No

BIOPSY

50957 URETER ENDOSCOPY & No

TREATMENT

50961 URETER ENDOSCOPY & No

TREATMENT

50970 URETER ENDOSCOPY No

50972 URETER ENDOSCOPY & No

CATHETER

50974 URETER ENDOSCOPY & No

BIOPSY

50976 URETER ENDOSCOPY & No

TREATMENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1146 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

50980 URETER ENDOSCOPY & No

TREATMENT

51020 INCISE & TREAT BLADDER No

51030 INCISE & TREAT BLADDER No

51040 INCISE & DRAIN BLADDER No

51045 INCISE BLADDER/DRAIN No

URETER

51050 REMOVAL OF BLADDER No

STONE

51060 REMOVAL OF URETER No

STONE

51065 REMOVE URETER No

CALCULUS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1147 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51080 DRAINAGE OF BLADDER No

ABSCESS

51100 DRAIN BLADDER BY No

NEEDLE

51101 DRAIN BLADDER BY No

TROCAR/CATH

51102 DRAIN BL W/CATH No

INSERTION

51500 REMOVAL OF BLADDER No

CYST

51520 REMOVAL OF BLADDER No

LESION

51525 REMOVAL OF BLADDER No

LESION

51530 REMOVAL OF BLADDER No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1148 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51535 REPAIR OF URETER No

LESION

51550 PARTIAL REMOVAL OF No

BLADDER

51555 PARTIAL REMOVAL OF No

BLADDER

51565 REVISE BLADDER & No

URETER(S)

51570 REMOVAL OF BLADDER No

51575 REMOVAL OF BLADDER & No

NODES

51580 REMOVE No
BLADDER/REVISE TRACT

51585 REMOVAL OF BLADDER & No

NODES

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1149 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51590 REMOVE No
BLADDER/REVISE TRACT

51595 REMOVE No
BLADDER/REVISE TRACT

51596 REMOVE No
BLADDER/CREATE POUCH

51597 REMOVAL OF PELVIC No

STRUCTURES

51600 INJECTION FOR BLADDER No

X-RAY

51605 PREPARATION FOR No

BLADDER XRAY

51610 INJECTION FOR BLADDER No

X-RAY

51700 IRRIGATION OF BLADDER No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1150 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51701 INSERT BLADDER No

CATHETER

51702 INSERT TEMP BLADDER No

CATH

51703 INSERT BLADDER CATH No

COMPLEX

51705 CHANGE OF BLADDER No

TUBE

51710 CHANGE OF BLADDER No

TUBE

51715 ENDOSCOPIC No
INJECTION/IMPLANT

51720 TREATMENT OF BLADDER No

LESION

51725 SIMPLE No
CYSTOMETROGRAM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1151 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51726 COMPLEX No
CYSTOMETROGRAM

51727 CYSTOMETROGRAM No
W/UP

51728 CYSTOMETROGRAM No
W/VP

51729 CYSTOMETROGRAM No
W/VP&UP

51736 URINE FLOW No

MEASUREMENT

51741 ELECTRO- No
UROFLOWMETRY FIRST

51784 ANAL/URINARY MUSCLE No

STUDY

51785 ANAL/URINARY MUSCLE No

STUDY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1152 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51792 URINARY REFLEX STUDY No

51797 INTRAABDOMINAL No
PRESSURE TEST

51798 US URINE CAPACITY No

MEASURE

51800 REVISION OF No
BLADDER/URETHRA

51820 REVISION OF URINARY No

TRACT

51840 ATTACH Yes InterQual® criteria used. Provide clinical

IQ - GU
BLADDER/URETHRA documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

51841 ATTACH Yes InterQual® criteria used. Provide clinical

IQ - GU
BLADDER/URETHRA documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

51845 REPAIR BLADDER NECK Yes InterQual® criteria used. Provide clinical
IQ - GU
documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1153 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51860 REPAIR OF BLADDER No

WOUND

51865 REPAIR OF BLADDER No

WOUND

51880 REPAIR OF BLADDER No

OPENING

51900 REPAIR No
BLADDER/VAGINA LESION

51920 CLOSE BLADDER-UTERUS No

FISTULA

51925 HYSTERECTOMY/BLADDE No
R REPAIR

51940 CORRECTION OF No
BLADDER DEFECT

51960 REVISION OF BLADDER & No

BOWEL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1154 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

51980 CONSTRUCT BLADDER No

OPENING

51990 LAPARO URETHRAL Yes InterQual® criteria used. Provide clinical

IQ - GU
SUSPENSION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

51992 LAPARO SLING Yes InterQual® criteria used. Provide clinical

IQ - GU
OPERATION documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

51999 LAPAROSCOPE PROC BLA No

52000 CYSTOSCOPY No

52001 CYSTOSCOPY REMOVAL No

OF CLOTS

52005 CYSTOSCOPY & URETER No* *PA req'd if performed as elective proc in
CATHETER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52007 CYSTOSCOPY AND BIOPSY No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1155 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52010 CYSTOSCOPY & DUCT No

CATHETER

52204 CYSTOSCOPY No
W/BIOPSY(S)

52214 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52224 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52234 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52235 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52240 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52250 CYSTOSCOPY AND No

RADIOTRACER

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1156 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52260 CYSTOSCOPY AND No

TREATMENT

52265 CYSTOSCOPY AND No

TREATMENT

52270 CYSTOSCOPY & REVISE No

URETHRA

52275 CYSTOSCOPY & REVISE No

URETHRA

52276 CYSTOSCOPY AND No

TREATMENT

52277 CYSTOSCOPY AND No

TREATMENT

52281 CYSTOSCOPY AND No

TREATMENT

52282 CYSTOSCOPY IMPLANT No

STENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1157 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52283 CYSTOSCOPY AND No

TREATMENT

52285 CYSTOSCOPY AND No

TREATMENT

52287 CYSTOSCOPY No
CHEMODENERVATION

52290 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52300 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52301 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52305 CYSTOSCOPY AND No

TREATMENT

52310 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1158 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52315 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52317 REMOVE BLADDER STONE No

52318 REMOVE BLADDER STONE No

52320 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52325 CYSTOSCOPY STONE No* *PA req'd if performed as elective proc in

REMOVAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52327 CYSTOSCOPY INJECT No* *PA req'd if performed as elective proc in

MATERIAL the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52330 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52332 CYSTOSCOPY AND No* *PA req'd if performed as elective proc in

TREATMENT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1159 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52334 CREATE PASSAGE TO No* *PA req'd if performed as elective proc in

KIDNEY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52341 CYSTO W/URETER No* *PA req'd if performed as elective proc in

STRICTURE TX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52342 CYSTO W/UP STRICTURE No* *PA req'd if performed as elective proc in
TX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52343 CYSTO W/RENAL No* *PA req'd if performed as elective proc in

STRICTURE TX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52344 CYSTO/URETERO No* *PA req'd if performed as elective proc in

STRICTURE TX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52345 CYSTO/URETERO W/UP No* *PA req'd if performed as elective proc in

STRICTURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52346 CYSTOURETERO No* *PA req'd if performed as elective proc in

W/RENAL STRICT the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52351 CYSTOURETERO & OR No* *PA req'd if performed as elective proc in

PYELOSCOPE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1160 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52352 CYSTOURETERO No* *PA req'd if performed as elective proc in

W/STONE REMOVE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52353 CYSTOURETERO No* *PA req'd if performed as elective proc in

W/LITHOTRIPSY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52354 CYSTOURETERO No* *PA req'd if performed as elective proc in

W/BIOPSY the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52355 CYSTOURETERO No* *PA req'd if performed as elective proc in

W/EXCISE TUMOR the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52356 CYSTO/URETERO No
W/LITHOTRIPSY

52400 CYSTOURETERO No
W/CONGEN REPR

52402 CYSTOURETHRO CUT No

EJACUL DUCT

52441 CYSTOURETHRO No
W/IMPLANT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1161 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52442 CYSTOURETHRO W/ADDL No

IMPLANT

52450 INCISION OF PROSTATE No

52500 REVISION OF BLADDER No

NECK

52601 PROSTATECTOMY (TURP) No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

52630 REMOVE PROSTATE No

REGROWTH

52640 RELIEVE BLADDER No

CONTRACTURE

52647 LASER SURGERY OF No

PROSTATE

52648 LASER SURGERY OF No* *PA req'd if performed as elective proc in

PROSTATE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1162 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

52649 PROSTATE LASER No

ENUCLEATION

52700 DRAINAGE OF PROSTATE No

ABSCESS

53000 INCISION OF URETHRA No

53010 INCISION OF URETHRA No

53020 INCISION OF URETHRA No

53025 INCISION OF URETHRA No

53040 DRAINAGE OF URETHRA No

ABSCESS

53060 DRAINAGE OF URETHRA No

ABSCESS

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1163 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53080 DRAINAGE OF URINARY No

LEAKAGE

53085 DRAINAGE OF URINARY No

LEAKAGE

53200 BIOPSY OF URETHRA No

53210 REMOVAL OF URETHRA No

53215 REMOVAL OF URETHRA No

53220 TREATMENT OF No
URETHRA LESION

53230 REMOVAL OF URETHRA No

LESION

53235 REMOVAL OF URETHRA No

LESION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1164 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53240 SURGERY FOR URETHRA No

POUCH

53250 REMOVAL OF URETHRA No

GLAND

53260 TREATMENT OF No
URETHRA LESION

53265 TREATMENT OF No
URETHRA LESION

53270 REMOVAL OF URETHRA No

GLAND

53275 REPAIR OF URETHRA No

DEFECT

53400 REVISE URETHRA STAGE 1 No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53405 REVISE URETHRA STAGE 2 No* *PA req'd if performed as elective proc in
the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1165 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53410 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53415 RECONSTRUCTION OF No* *PA req'd if performed as elective proc in

URETHRA the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53420 RECONSTRUCT URETHRA No* *PA req'd if performed as elective proc in

STAGE 1 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53425 RECONSTRUCT URETHRA No* *PA req'd if performed as elective proc in

STAGE 2 the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53430 RECONSTRUCTION OF Yes This policy applies to this code when billed
URETHRA with DX code(s) F64.1-F64.9 and/or
Z87.890

53431 RECONSTRUCT No* *PA req'd if performed as elective proc in

URETHRA/BLADDER the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53440 MALE SLING PROCEDURE Yes* InterQual® criteria used. *Will be covered
IQ - GU
only when performed in the Outpatient
Surgery setting.

53442 REMOVE/REVISE MALE No

SLING

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1166 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53444 INSERT TANDEM CUFF No

53445 INSERT URO/VES NCK No

SPHINCTER

53446 REMOVE URO SPHINCTER No

53447 REMOVE/REPLACE UR No
SPHINCTER

53448 REMOV/REPLC UR No
SPHINCTR COMP

53449 REPAIR URO SPHINCTER No

53450 REVISION OF URETHRA No

53460 REVISION OF URETHRA No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1167 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53500 URETHRLYS TRANSVAG No

W/ SCOPE

53502 REPAIR OF URETHRA No

INJURY

53505 REPAIR OF URETHRA No

INJURY

53510 REPAIR OF URETHRA No

INJURY

53515 REPAIR OF URETHRA No

INJURY

53520 REPAIR OF URETHRA No

DEFECT

53600 DILATE URETHRA No

STRICTURE

53601 DILATE URETHRA No

STRICTURE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1168 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53605 DILATE URETHRA No

STRICTURE

53620 DILATE URETHRA No

STRICTURE

53621 DILATE URETHRA No

STRICTURE

53660 DILATION OF URETHRA No

53661 DILATION OF URETHRA No

53665 DILATION OF URETHRA No

53850 PROSTATIC MICROWAVE No* *PA req'd if performed as elective proc in

THERMOTX the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

53852 PROSTATIC RF THERMOTX No* *PA req'd if performed as elective proc in

the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1169 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

53855 INSERT PROST URETHRAL No

STENT

53860 TRANSURETHRAL RF No
TREATMENT

53899 UROLOGY SURGERY No* *PA req'd if performed as elective proc in

PROCEDURE the Inpatient setting; incl all clinical
documentation that supports the need for
inpatient level of care.

Emerging Technology

0019T EXTRACORP SHOCK WV Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TX MS NOS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0051T IMPLANT TOTAL HEART Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
SYSTEM more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0052T REPLACE THRC UNIT HRT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
SYST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0053T REPLACE IMPLANTABLE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
HRT SYST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1170 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0054T BONE SRGRY CMPTR No

FLUOR IMAGE

0055T BONE SRGRY CMPTR No

CT/MRI IMAG

0058T CRYOPRESERVATION Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
OVARY TISS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0071T US LEIOMYOMATA Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ABLATE <200 more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0072T US LEIOMYOMATA Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ABLATE >200 more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0075T PERQ STENT/CHEST VERT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ART more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0076T S&I STENT/CHEST VERT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ART more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0085T BREATH TEST HEART Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
REJECT more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1171 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0095T RMVL ARTIFIC DISC ADDL Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
CRVCL more details Replacement (Eff 03/01/18)

0098T REV ARTIFIC DISC ADDL Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
Spine Surgery
more details Replacement (Eff 03/01/18)

0100T PROSTH RETINA Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
RECEIVE&GEN more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0101T EXTRACORP SHOCKWV Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TX HI ENRG more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0102T EXTRACORP SHOCKWV Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TX ANESTH more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0106T TOUCH QUANT SENSORY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0107T VIBRATE QUANT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
SENSORY TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0108T COOL QUANT SENSORY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1172 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0109T HEAT QUANT SENSORY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0110T NOS QUANT SENSORY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
TEST more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0111T RBC MEMBRANES FATTY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ACIDS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0126T CHD RISK IMT STUDY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0163T LUMB ARTIF No

DISKECTOMY ADDL

0164T REMOVE LUMB ARTIF No

DISC ADDL

0165T REVISE LUMB ARTIF DISC No

ADDL

0169T PLACE STEREO CATH Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
BRAIN more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1173 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0174T CAD CXR WITH INTERP Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0175T CAD CXR REMOTE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0178T 64 LEAD ECG W/I&R Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0179T 64 LEAD ECG W/TRACING Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0180T 64 LEAD ECG W/I&R ONLY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0184T EXC RECTAL TUMOR Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ENDOSCOPIC more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0188T VIDEOCONF CRIT CARE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
74 MIN more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0189T VIDEOCONF CRIT CARE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ADDL 30 more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1174 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0190T PLACE INTRAOC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
RADIATION SRC more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0191T INSERT ANT SEGMENT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DRAIN INT more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0195T PRESCRL FUSE W/O Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
INSTR L5/S1 more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0196T PRESCRL FUSE W/O Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
INSTR L4/L5 more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0198T OCULAR BLOOD FLOW Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
MEASURE more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0200T PERQ SACRAL AUGMT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
UNILAT INJ more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0201T PERQ SACRAL AUGMT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
BILAT INJ more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0202T POST VERT ARTHRPLST 1 Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
LUMBAR more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1175 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0205T INIRS EACH VESSEL ADD- Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ON more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0206T CPTR DBS ALYS CAR ELEC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DTA more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0207T CLEAR EYELID GLAND Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
W/HEAT more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0208T AUDIOMETRY AIR ONLY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0209T AUDIOMETRY AIR & BONE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0210T SPEECH AUDIOMETRY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
THRESHOLD more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0211T SPEECH AUDIOM THRESH Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
& RECOG more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0212T COMPRE AUDIOMETRY Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
EVALUATION more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1176 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0213T NJX PARAVERT W/US Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
CER/THOR *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

0214T NJX PARAVERT W/US Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
CER/THOR *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

0215T NJX PARAVERT W/US Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
CER/THOR *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

0216T NJX PARAVERT W/US Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LUMB/SAC *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

0217T NJX PARAVERT W/US Yes* Please review BMCHP criteria for details. Facet Joint Nerve Injections Facet Joint Nerve Injections
NH-Facet Joint
LUMB/SAC *Will be covered only when performed in (Eff 05/01/18)
Nerve the Outpatient setting.
Injection

0218T NJX PARAVERT W/US Yes Please review the Well Sense Policy for
NH-Facet Joint
LUMB/SAC more details
Nerve
Injection

0219T PLMT POST FACET IMPLT Yes InterQual® criteria used. Provide clinical
IQ - Spine
CERV documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

0220T PLMT POST FACET IMPLT Yes InterQual® criteria used. Provide clinical
IQ - Spine
THOR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1177 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0221T PLMT POST FACET IMPLT Yes InterQual® criteria used. Provide clinical
IQ - Spine
LUMB documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

0222T PLMT POST FACET IMPLT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ADDL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0228T NJX TFRML EPRL W/US Yes InterQual® criteria used. Provide clinical
IQ - Spine
CER/THOR documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

0229T NJX TFRML EPRL W/US Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
CER/THOR more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0230T NJX TFRML EPRL W/US Yes InterQual® criteria used. Provide clinical
IQ - Spine
LUMB/SAC documentation supporting rationale for
Surgery request (e.g., notes, lab values, X-rays, etc.)

0231T NJX TFRML EPRL W/US Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
LUMB/SAC more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0232T NJX PLATELET PLASMA Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0234T TRLUML PERIP ATHRC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
RENAL ART more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1178 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0235T TRLUML PERIP ATHRC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
VISCERAL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0236T TRLUML PERIP ATHRC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
ABD AORTA more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0237T TRLUML PERIP ATHRC Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
BRCHIOCPH more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0238T TRLUML PERIP ATHRC Yes Please review the Well Sense Policy for InterQual® criteria is available
NH-
ILIAC ART more details
Experimental/I
nvestigation

0249T LIGATION HEMORRHOID Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
W/US more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0253T INSERT AQUEOUS DRAIN Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEVICE more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0254T EVASC RPR ILIAC ART Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
BIFUR more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0255T EVASC RPR ILIAC ART Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
BIFR S&I more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1179 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0263T IM B1 MRW CEL THER Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
CMPL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0264T IM B1 MRW CEL THER Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
XCL HRVST more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0265T IM B1 MRW CEL THER Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
HRVST ONL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0266T IMPLT/RPL CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEV TOTAL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0267T IMPLT/RPL CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEV LEAD more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0268T IMPLT/RPL CRTD SNS Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DEV GEN more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0269T REV/REMVL CRTD SNS Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DEV TOTAL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0270T REV/REMVL CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEV LEAD more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1180 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0271T REV/REMVL CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEV GEN more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0272T INTERROGATE CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEV more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0273T INTERROGATE CRTD SNS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
W/PGRMG more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0274T PERQ LAMOT/LAM Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
NH-Thermal
CRV/THRC more details Back Pain Treatments for Back Pain (Eff
Intradiscal 03/01/18)
Surg

0275T PERQ LAMOT/LAM Yes Please review the Well Sense Policy for Minimally Invasive Treatments for Minimally Invasive
NH-Thermal
LUMBAR more details Back Pain Treatments for Back Pain (Eff
Intradiscal 03/01/18)
Surg

0278T TEMPR Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0281T LAA CLOSURE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
W/IMPLANT more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0282T PERIPH FIELD STIMUL Yes Provide clinical documentation supporting

IQ - Spine
TRIAL rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1181 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0283T PERIPH FIELD STIMUL Yes Provide clinical documentation supporting

IQ - Spine
PERM rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

0284T PERIPH FIELD STIMUL Yes Provide clinical documentation supporting

IQ - Spine
REVISE rationale for request (e.g., notes, lab
Surgery values, X-rays, etc.)

0285T PERIPH FIELD STIMUL No

ANALYS

0286T NEAR IFR SPECTRSC OF Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
WOUNDS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0287T NEAR IFR GUIDE OF VASC Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
SITE more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0288T ANOSCOPY W/RF Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DELIVERY more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0289T LASER INC FOR PKP/LKP Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
DONOR more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0290T LASER INC FOR PKP/LKP Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
RECIP more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1182 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0291T IV OCT FOR PROC INIT Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
VESSEL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0292T IV OCT FOR PROC ADDL Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
VESSEL more details Treatment Investigational Treatmen
Experimental/I
nvestigation

0293T INS LT ATRL PRESS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
MONITOR more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0294T INS LT ATRL MONT PRES Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
LEAD more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0295T EXT ECG COMPLETE Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

0296T EXT ECG RECORDING Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

0297T EXT ECG SCAN W/REPORT Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

0298T EXT ECG REVIEW AND Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
NH-Amb
INTERP more details (Excluding Holter Monitors) Monitors (Excluding Holter
Cardiac Event Monitors) ( Eff 01/01/19)
Monitor

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1183 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0299T ESW WOUND HEALING Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
INIT WOUND more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0300T ESW WOUND HEALING Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ADDL WOUND more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0301T MW THERAPY FOR Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
BREAST TUMOR more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0302T ICAR ISCHM MNTRNG SYS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
COMPL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0303T ICAR ISCHM MNTRNG SYS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ELTRD more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0304T ICAR ISCHM MNTRNG SYS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DEVICE more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0305T ICAR ISCHM MNTRNG Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
PRGRM EVAL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0306T ICAR ISCHM MNTR Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
INTERR EVAL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1184 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0307T RMVL ICAR ISCHM Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
MNTRNG DVCE more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0308T INSJ OCULAR TELESCOPE Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
PROSTH more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0329T MNTR IO PRESS 24HRS/> Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
UNI/BI more details. Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0331T HEART SYMP IMAGE PLNR Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
more details. Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0332T HEART SYMP IMAGE Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
PLNR SPECT more details. Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0333T VISUAL EP ACUITY No

SCREEN AUTO

0335T EXTRAOSSEOUS JOINT Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
STBLZTION more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0336T LAP ABLAT UTERINE Yes Please review the Well Sense Policy for Experimental And Investigational Experimental And
NH-
FIBROIDS more details Treatment Investigational Treatmen
Experimental/I
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1185 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0337T ENDOTHEL FXNASSMNT Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
NON-INVAS more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0338T TRNSCTH RENAL SYMP Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DENRV UNL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0339T TRNSCTH RENAL SYMP Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DENRV BIL more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0340T ABLATE PULM TUMORS Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
EXTNSN more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0341T QUANT PUPILLOMETRY Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
W/RPRT more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0342T THXP APHERESIS W/HDL Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
DELIP more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0345T TRANSCATH MTRAL VLVE Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
REPAIR more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

0346T ULTRASOUND Yes Please review the Well Sense Policy for Experimental and Investigational Experimental and
NH-
ELASTOGRAPHY more details Treatment Investigational Treatment (Eff
Experimental/I 07/01/18)
nvestigation

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1186 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0375T TOTAL DISC ARTHRP ANT Yes Please review the Well Sense Policy for Cervical Artificial Disc Replacement Cervical Artificial Disc
NH-Thermal
APPR more details Replacement (Eff 03/01/18)
Intradiscal
Surg

0376T INSERT ANT SEGMENT No

DRAIN INT

0377T ANOSCPY INJ AGENT FOR No

INCONT

0378T VISUAL FIELD ASSMNT No

REV/RPRT

0379T VIS FIELD ASSMNT TECH No

SUPPT

0380T COMP ANIMAT RET IMAG No

SERIES

0381T EXT H RATE EPI SZ 14 No

DAYS

0382T EXT H RATE SZ 14 DAY RI No

ONLY

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1187 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0383T EXT H RATE SZ 15-30 No

DAYS

0384T EX H RATE SZ 30 DAY RI No

ONLY

0385T EX H RATE FOR SZ OVR 30 No

DAY

0386T EX H RATE SZ 30+ DAY RI No

ONLY

0387T LEADLESS PM INS/RPL No

VENTR

0388T LEADLESS PM REMOVE No

VENTR

0389T PROG EVAL INPER No

LEADLS PM

0390T PERIPROC EVAL INPER No

LEDLS PM

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1188 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0391T INTERGT EVAL INPER No

LEADLS PM

0392T LAP ES SPH AUGMENT No

DEV PLACE

0393T ES SPH AUGMNT DEVICE No

REMOVAL

0394T HDR ELCTRNC SKN SURF No

BRCHYTX

0395T HDR ELCTR No

NTRST/NTRCV BRCHTX

0396T INTRAOP KINETIC No

BALNCE SENSR

0397T ERCP W/OPTICAL No

ENDOMICROSCPY

0398T MRGFUS STRTCTC LES No

ABLTJ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1189 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0399T MYOCARDIAL STRAIN No

IMAGING

0400T MLTISPECTRL DIGITAL Whole Body Integumentary Whole Body Integumentary

LES ALYS Photography and Dermatoscopy Photography and
Dermatoscopy (Eff10/01/18)

0401T MLTISPECTRL DIGITAL Whole Body Integumentary Whole Body Integumentary

LES ALYS Photography and Dermatoscopy Photography and
Dermatoscopy (Eff10/01/18)

0402T COLLAGEN No
CROSSLINKING CORNEA

0403T DIABETES PREV No

STANDARD CURR

0404T TRNSCRV UTERIN No

FIBROID ABLTJ

0405T OVRSGHT XTRCORP LIV No

ASST PAT

0406T SIN NDSC PLMT DRG No

ELUT MPLNT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1190 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0407T SIN NDSC PLMT DRG No

ELUT MPLNT

0446T INSJ IMPLTBL GLUCOSE Yes Please review the Well Sense Policy for Continuous Glucose Monitoring Continuous Glucose
SENSOR more details Systems and Insulin Delivery Devices Monitoring Systems and
Insulin Delivery Devices (Eff
01/01/19)

0448T REMVL INSJ IMPLTBL Yes Please review the Well Sense Policy for Continuous Glucose Monitoring Continuous Glucose
GLUC SENS more details Systems and Insulin Delivery Devices Monitoring Systems and
Insulin Delivery Devices (Eff
01/01/19)

0498T XTRNL PT ACT ECG R&I Yes Please review the Well Sense Policy for Ambulatory Cardiac Event Monitors Ambulatory Cardiac Event
PR 30 D more details (Excluding Holter Monitors) Monitors (Excluding Holter
Monitors) ( Eff 01/01/19)

0500T HPV 5+ HI RISK HPV TYPES Yes Please review the Well Sense Policy for Genetic Testing Guidelines and Genetic/Genomic Testing and Genetic/Genomic
NH-Genetic
more details Pharmacogenetics Pharmacogenetics (Eff Testing and
Testing 12/01/18 and Retired Pharmacogenetics (Eff
03/31/19) 04/01/19)

0537T BLD DRV T LYMPHCYT Yes Please review the Well Sense Policy for CAR T-Cell Therapy with Kymriah or CAR T-Cell Therapy with
CAR-T CLL more details Yescarta to Treat Hematological KYMRIAH® or YESCARTA® to
Malignancies Treat (Effective 01/01/19)

0538T BLD DRV T LYMPHCYT Yes Please review the Well Sense Policy for CAR T-Cell Therapy with Kymriah or CAR T-Cell Therapy with
PREP TRNS more details Yescarta to Treat Hematological KYMRIAH® or YESCARTA® to
Malignancies Treat (Effective 01/01/19)

0539T RECEIPT&PREP CAR-T CLL Yes Please review the Well Sense Policy for CAR T-Cell Therapy with Kymriah or CAR T-Cell Therapy with
ADMN more details Yescarta to Treat Hematological KYMRIAH® or YESCARTA® to
Malignancies Treat (Effective 01/01/19)

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1191 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

0540T CAR-T CLL ADMN Yes Please review the Well Sense Policy for CAR T-Cell Therapy with Kymriah or CAR T-Cell Therapy with
AUTOLOGOUS more details Yescarta to Treat Hematological KYMRIAH® or YESCARTA® to
Malignancies Treat (Effective 01/01/19)

Evaluation and Management

Advance Care Planning
99497 ADVNCD CARE PLAN 30 No
MIN

99498 ADVNCD CARE PLAN No

ADDL 30 MIN

Care Management Services

99487 CMPLX CHRON CARE No
W/O PT VSIT

99489 CMPLX CHRON CARE No

ADDL 30 MIN

99490 CHRON CARE MGMT No

SRVC 20 MIN

Care plan oversight services

99374 HOME HEALTH CARE No
SUPERVISION

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1192 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99375 HOME HEALTH CARE No

SUPERVISION

99377 HOSPICE CARE No

SUPERVISION

99378 HOSPICE CARE No

SUPERVISION

99379 NURSING FAC CARE No

SUPERVISION

99380 NURSING FAC CARE No

SUPERVISION

Case management services

99363 ANTICOAGULANT MGMT No
INITIAL

99364 ANTICOAGULANT MGMT No

SUBSEQ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1193 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99366 TEAM CONF W/PAT BY No

HC PROF

99367 TEAM CONF W/O PAT BY No

PHYS

99368 TEAM CONF W/O PAT BY No

HC PRO

Consultations
99241 OFFICE CONSULTATION No

99242 OFFICE CONSULTATION No

99243 OFFICE CONSULTATION No

99244 OFFICE CONSULTATION No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1194 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99245 OFFICE CONSULTATION No

99251 INPATIENT No
CONSULTATION

99252 INPATIENT No
CONSULTATION

99253 INPATIENT No
CONSULTATION

99254 INPATIENT No
CONSULTATION

99255 INPATIENT No
CONSULTATION

Critical care services

99291 CRITICAL CARE FIRST No
HOUR

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1195 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99292 CRITICAL CARE ADDL 30 No

MIN

Delivery/Birthing Room Attendance and Resuscitation Services

99464 ATTENDANCE AT No
DELIVERY

99465 NB RESUSCITATION No

Domiciliary, rest home (assisted living facility), or home care plan oversight services
99339 DOMICIL/R-HOME CARE No
SUPERVIS

99340 DOMICIL/R-HOME CARE No

SUPERVIS

Domiciliary, rest home (boarding home) or custodial care services

99324 DOMICIL/R-HOME VISIT No
NEW PAT

99325 DOMICIL/R-HOME VISIT No

NEW PAT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1196 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99326 DOMICIL/R-HOME VISIT No

NEW PAT

99327 DOMICIL/R-HOME VISIT No

NEW PAT

99328 DOMICIL/R-HOME VISIT No

NEW PAT

99334 DOMICIL/R-HOME VISIT No

EST PAT

99335 DOMICIL/R-HOME VISIT No

EST PAT

99336 DOMICIL/R-HOME VISIT No

EST PAT

99337 DOMICIL/R-HOME VISIT No

EST PAT

Emergency department services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1197 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99281 EMERGENCY DEPT VISIT No

99282 EMERGENCY DEPT VISIT No

99283 EMERGENCY DEPT VISIT No

99284 EMERGENCY DEPT VISIT No

99285 EMERGENCY DEPT VISIT No

99288 DIRECT ADVANCED LIFE No

SUPPORT

Home health services

99341 HOME VISIT NEW No
PATIENT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1198 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99342 HOME VISIT NEW No

PATIENT

99343 HOME VISIT NEW No

PATIENT

99344 HOME VISIT NEW No

PATIENT

99345 HOME VISIT NEW No

PATIENT

99347 HOME VISIT EST PATIENT No

99348 HOME VISIT EST PATIENT No

99349 HOME VISIT EST PATIENT No

99350 HOME VISIT EST PATIENT No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1199 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

Hospital inpatient services

99221 INITIAL HOSPITAL CARE No

99222 INITIAL HOSPITAL CARE No

99223 INITIAL HOSPITAL CARE No

99224 SUBSEQUENT No
OBSERVATION CARE

99225 SUBSEQUENT No
OBSERVATION CARE

99226 SUBSEQUENT No
OBSERVATION CARE

99231 SUBSEQUENT HOSPITAL No

CARE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1200 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99232 SUBSEQUENT HOSPITAL No

CARE

99233 SUBSEQUENT HOSPITAL No

CARE

99234 OBSERV/HOSP SAME No

DATE

99235 OBSERV/HOSP SAME No

DATE

99236 OBSERV/HOSP SAME No

DATE

99238 HOSPITAL DISCHARGE No

DAY

99239 HOSPITAL DISCHARGE No

DAY

Hospital observation services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1201 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99217 OBSERVATION CARE No* *Notification for Observation Stays is

DISCHARGE required.

99218 INITIAL OBSERVATION No* *Notification for Observation Stays is

CARE required.

99219 INITIAL OBSERVATION No* *Notification for Observation Stays is

CARE required.

99220 INITIAL OBSERVATION No* *Notification for Observation Stays is

CARE required.

Inpatient neonatal intensive, and pediatric/neonatal critical, care services

99466 PED CRIT CARE No
TRANSPORT

99467 PED CRIT CARE No

TRANSPORT ADDL

99468 NEONATE CRIT CARE No

INITIAL

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1202 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99469 NEONATE CRIT CARE No

SUBSQ

99471 PED CRITICAL CARE No

INITIAL

99472 PED CRITICAL CARE No

SUBSQ

99475 PED CRIT CARE AGE 2-5 No

INIT

99476 PED CRIT CARE AGE 2-5 No

SUBSQ

99477 INIT DAY HOSP NEONATE No

CARE

99478 IC LBW INF < 1500 GM No

SUBSQ

99479 IC LBW INF 1500-2500 G No

SUBSQ

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1203 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99480 IC INF PBW 2501-5000 G No

SUBSQ

99485 SUPRV INTERFACILTY No

TRANSPORT

99486 SUPRV INTERFAC No

TRNSPORT ADDL

Newborn care services

99460 INIT NB EM PER DAY No
HOSP

99461 INIT NB EM PER DAY No

NON-FAC

99462 SBSQ NB EM PER DAY No

HOSP

99463 SAME DAY NB DISCHARGE No

Non-face-to-face physician services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1204 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99441 PHONE E/M PHYS/QHP 5- No

10 MIN

99442 PHONE E/M PHYS/QHP No

11-20 MIN

99443 PHONE E/M PHYS/QHP No

21-30 MIN

99444 ONLINE E/M BY No

PHYS/QHP

Nursing facility services

99304 NURSING FACILITY CARE No
INIT

99305 NURSING FACILITY CARE No

INIT

99306 NURSING FACILITY CARE No

INIT

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1205 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99307 NURSING FAC CARE No

SUBSEQ

99308 NURSING FAC CARE No

SUBSEQ

99309 NURSING FAC CARE No

SUBSEQ

99310 NURSING FAC CARE No

SUBSEQ

99315 NURSING FAC No

DISCHARGE DAY

99316 NURSING FAC No

DISCHARGE DAY

99318 ANNUAL NURSING FAC No

ASSESSMNT

Office/other outpatient services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1206 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99201 OFFICE/OUTPATIENT No
VISIT NEW

99202 OFFICE/OUTPATIENT No
VISIT NEW

99203 OFFICE/OUTPATIENT No
VISIT NEW

99204 OFFICE/OUTPATIENT No
VISIT NEW

99205 OFFICE/OUTPATIENT No
VISIT NEW

99211 OFFICE/OUTPATIENT No
VISIT EST

99212 OFFICE/OUTPATIENT No
VISIT EST

99213 OFFICE/OUTPATIENT No
VISIT EST

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1207 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99214 OFFICE/OUTPATIENT No
VISIT EST

99215 OFFICE/OUTPATIENT No
VISIT EST

Other evaluation and management services

99499 UNLISTED E&M SERVICE No

Preventive medicine services

99381 INIT PM E/M NEW PAT No
INFANT

99382 INIT PM E/M NEW PAT 1- No

4 YRS

99383 PREV VISIT NEW AGE 5-11 No

99384 PREV VISIT NEW AGE 12- No

17

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1208 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99385 PREV VISIT NEW AGE 18- No

39

99386 PREV VISIT NEW AGE 40- No

64

99387 INIT PM E/M NEW PAT No

65+ YRS

99391 PER PM REEVAL EST PAT No

INFANT

99392 PREV VISIT EST AGE 1-4 No

99393 PREV VISIT EST AGE 5-11 No

99394 PREV VISIT EST AGE 12-17 No

99395 PREV VISIT EST AGE 18-39 No

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1209 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99396 PREV VISIT EST AGE 40-64 No

99397 PER PM REEVAL EST PAT No

65+ YR

99401 PREVENTIVE No
COUNSELING INDIV

99402 PREVENTIVE No
COUNSELING INDIV

99403 PREVENTIVE No
COUNSELING INDIV

99404 PREVENTIVE No
COUNSELING INDIV

99406 BEHAV CHNG SMOKING 3- No

10 MIN

99407 BEHAV CHNG SMOKING > No

10 MIN

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1210 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99408 AUDIT/DAST 15-30 MIN No

99409 AUDIT/DAST OVER 30 No

MIN

99411 PREVENTIVE No
COUNSELING GROUP

99412 PREVENTIVE No
COUNSELING GROUP

99415 PROLONG CLINCL STAFF No

SVC

99416 PROLONG CLINCL STAFF No

SVC ADD

99420 HEALTH RISK No

ASSESSMENT TEST

99429 UNLISTED PREVENTIVE No

SERVICE

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1211 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

Prolonged services
99354 PROLONG E&M/PSYCTX No
SERV O/P

99355 PROLONG E&M/PSYCTX No

SERV O/P

99356 PROLONGED SERVICE No

INPATIENT

99357 PROLONGED SERVICE No

INPATIENT

99358 PROLONG SERVICE W/O No

CONTACT

99359 PROLONG SERV W/O No

CONTACT ADD

99360 PHYSICIAN STANDBY No

SERVICES

Special evaluation and management services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1212 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99446 INTERPROF No
PHONE/ONLINE 5-10

99447 INTERPROF No
PHONE/ONLINE 11-20

99448 INTERPROF No
PHONE/ONLINE 21-30

99449 INTERPROF No
PHONE/ONLINE 31/>

99450 BASIC LIFE DISABILITY No

EXAM

99455 WORK RELATED No

DISABILITY EXAM

99456 DISABILITY EXAMINATION No

Transitional care management services

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1213 of 1214
Code Short Description Well Sense Message PolicyName WebAddress WebAddress 2
PA Req'd?

99495 TRANS CARE MGMT 14 No

DAY DISCH

99496 TRANS CARE MGMT 7 No

DAY DISCH

This tool does not address member benefits/coverage. While any given code may be listed as not requiring prior authorization, payment will be denied if the associated service is not a benefit under the member’s plan.
Please refer to the member’s benefit documents and/or Plan Reimbursement Policies for additional information regarding benefits/coverage.
Wednesday, February 06, 2019 Well Sense Health Plan Page 1214 of 1214