Prior Authorization Reference Guide – Medicaid

  • The purpose of these guides (below, by line of business) is to inform you of services that require prior authorization.
  • If you do not find a specific service listed on these guides, it may be that the service is a non-covered benefit. If you need information related to covered services, please refer to our Billing Guidelines and Coverage Summaries or call Neighborhood Provider Services at 1-800-963-1001.
  • All Acute and Post-Acute admissions require authorization.
  • Neighborhood Health Plan of RI utilizes the following criteria to make medical review decisions:
    • InterQual
    • Clinical Medical Policies
  • Access Prior Authorization Forms here.  Forms can be completed online or submitted to the 24/7 fax line at 401-459-6023.If you have any questions about the authorization process, please call Utilization Management at 401-459-6060.
  • For the following areas: Radiology, Oncology and Durable Medical Equipment please see our partnered vendor information below regarding authorization requirements

 

Radiology Authorization Information

Radiology Authorizations

Neighborhood has partnered with eviCore Healthcare for prior authorization of outpatient elective CT, MR, PET, CT Cardiac, MR Cardiac, PET Cardiac, Nuclear Cardiology and 3D Rendering Procedures.  Out of Network Providers: Please see NHPRI auth guide for additional radiology codes that may require auth

Please note: Neighborhood and eviCore will accept authorizations from either the ordering or rendering provider prior to the service being rendered.

Additional resources:

For more information visit eviCore.

Oncology Authorization Information

Oncology Authorizations

Neighborhood has partnered with New Century Health – Program for oncology-related drugs and/or treatment.

ICD-10, CPT and HCPC code list for Genomic and Radiation Oncology as of 4-1-2021.pdf

 

Durable Medical Equipment (DME) Authorization Information

DME Authorizations

Neighborhood has partnered with DMEnsion Benefit Manager- processes claims and manages the DME vendor network for DME delivered in the home. Please see NHPRI auth guide for DME HCPC codes rendered in POS other than 12(home).

 

CodeCode DescriptionAuthorization Required RIte Care (MED), CSN, and Sub CareAuthorization Required RHODY HEALTH EXPANSION (RHE) RHODY HEALTH PARTNERS (RHP)Authorization Required Extended Family Planning (EFP)CommentsForm Link
10004Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10005Fine needle aspiration biopsy, including ultrasound guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10006Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10007Fine needle aspiration biopsy, including fluoroscopic guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10008Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10009Fine needle aspiration biopsy, including CT guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10010Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10011Fine needle aspiration biopsy, including MR guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10012Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10021Fine needle aspiration biopsy, without imaging guidance; first lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10030Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10035Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10036Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10040Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10060Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10061Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multipleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10080Incision and drainage of pilonidal cyst; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10081Incision and drainage of pilonidal cyst; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10120Incision and removal of foreign body, subcutaneous tissues; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10121Incision and removal of foreign body, subcutaneous tissues; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10140Incision and drainage of hematoma, seroma or fluid collectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10160Puncture aspiration of abscess, hematoma, bulla, or cystSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
10180Incision and drainage, complex, postoperative wound infectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11000Debridement of extensive eczematous or infected skin; up to 10% of body surfaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11001Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11004Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11005Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11006Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11008Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11010Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissuesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11011Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11012Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11042Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11043Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11044Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11045Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11046Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11047Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11055Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11056Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11057Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11102Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11103Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11104Punch biopsy of skin (including simple closure, when performed); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11105Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11106Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11107Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11200Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesionsYesYesNon-Covered BenefitOutpatient Surgery e-form
11201Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof YesYesNon-Covered BenefitOutpatient Surgery e-form
11300Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11301Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11302Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11303Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11305Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11306Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11307 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11308Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11310Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11311Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11312Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11313Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11400Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less. (Complex or layered closure is reported separately, if required. Each lesion removed is reported separately.) YesYesNon-Covered BenefitOutpatient Surgery e-form
11401Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm. (Complex or layered closure is reported separately, if required. Each lesion removed is reported separately.)YesYesNon-Covered BenefitOutpatient Surgery e-form
11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11403Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11404Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11406Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11420Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11421Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11422Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11423Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11424Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11426Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11440 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11444 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11446Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11450Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11451Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11462Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11463Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11470Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11471Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11600Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11601Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11602Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11603Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11604Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11606Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11620Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11621Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11622Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11623Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11624Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11626Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11640Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
11641Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
11642Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
11643Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11644Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11646Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11730Avulsion of nail plate, partial or complete, simple; singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11732Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11740Evacuation of subungual hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11750Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11755Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11760Repair of nail bedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11762Reconstruction of nail bed with graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11765Wedge excision of skin of nail fold (eg, for ingrown toenail)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11770Excision of pilonidal cyst or sinus; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11771Excision of pilonidal cyst or sinus; extensiveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11772Excision of pilonidal cyst or sinus; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11900Injection, intralesional; up to and including 7 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11901Injection, intralesional; more than 7 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11920Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11921Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cmYesYesNon-Covered BenefitOutpatient Surgery e-form
11922Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-form
11950Subcutaneous injection of filling material (eg, collagen); 1 cc or lessYesYesNon-Covered BenefitOutpatient Surgery e-form
11951Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-form
11952Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-form
11954Subcutaneous injection of filling material (eg, collagen); over 10.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-form
11960Insertion of tissue expander(s) for other than breast, including subsequent expansionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11970Replacement of tissue expander with permanent prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
11971Removal of tissue expander(s) without insertion of prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
11976Removal, implantable contraceptive capsulesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11980Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
11981Insertion, non-biodegradable drug delivery implantSee CommentSee CommentSee CommentIn Network Authorization is required for Extended Family Planning (EFP) members only.
Out of Network:Authorization is required for all benefit plans
Out of Network e-form
11982Removal, non-biodegradable drug delivery implantSee CommentSee CommentSee CommentIn Network: Authorization is required for Extended Family Planning (EFP) members only.
Out of Network:Authorization is required for all benefit plans.
Outpatient Surgery e-form
Out of Network e-form
11983Removal with reinsertion, non-biodegradable drug delivery implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12001Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12002Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12004Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12005Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12006Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12007Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12011Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12013Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12014Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12015Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12016Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12017Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12018Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12020Treatment of superficial wound dehiscence; simple closureSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12021Treatment of superficial wound dehiscence; with packingSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12031Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12032Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12034Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12035Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12036Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12037Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12041Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12042Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12044Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12045Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12046Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12047Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
12051Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12052Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12053Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12054Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12055Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12056Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
12057Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13100Repair, complex, trunk; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13101Repair, complex, trunk; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13102Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13120Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13121Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13122Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
13131Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13132Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13133Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13150Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13151Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13152Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13153Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
13160Secondary closure of surgical wound or dehiscence, extensive or complicatedSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14000Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14001Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14020Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14021Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14040Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14041Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14060Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14061Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14300Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any areaSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
14301Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
14302Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
14350Filleted finger or toe flap, including preparation of recipient siteSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15002Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15003Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15004Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15005Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15040Harvest of skin for tissue cultured skin autograft, 100 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15050Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15100Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15101Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15110Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15111Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15115Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15116Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15120Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15121Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15130Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15131Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15135Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15136Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15150Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15151Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15152Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15155Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15156Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15157Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15200Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15201Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15220Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15221Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15240Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15241Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15260Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15261Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
15271Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15272Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15273Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15274Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15275Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15276Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15277Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and childrenSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15278Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15570Formation of direct or tubed pedicle, with or without transfer; trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15572Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15574Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feetSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15576Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15600Delay of flap or sectioning of flap (division and inset); at trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15610Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15620Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feetSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15630Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lipsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15650Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any locationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15730Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15731Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15733Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15734Muscle, myocutaneous, or fasciocutaneous flap; trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15736Muscle, myocutaneous, or fasciocutaneous flap; upper extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15738Muscle, myocutaneous, or fasciocutaneous flap; lower extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15740Flap; island pedicle requiring identification and dissection of an anatomically named axial vesselSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15750Flap; neurovascular pedicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15756Free muscle or myocutaneous flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15757Free skin flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15758Free fascial flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15760Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15770Graft; derma-fat-fasciaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15777Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15780Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15781Dermabrasion; segmental, faceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15782Dermabrasion; regional, other than faceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15783Dermabrasion; superficial, any site (eg, tattoo removal)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15786Abrasion; single lesion (eg, keratosis, scar)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15787Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-form
15788Chemical peel, facial; epidermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15789Chemical peel, facial; dermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15792Chemical peel, nonfacial; epidermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15793Chemical peel, nonfacial; dermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15819CervicoplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15820Blepharoplasty, lower eyelidYesYesNon-Covered BenefitOutpatient Surgery e-form
15821Blepharoplasty, lower eyelid; with extensive herniated fat padYesYesNon-Covered BenefitOutpatient Surgery e-form
15822Blepharoplasty, upper eyelid;YesYesNon-Covered BenefitOutpatient Surgery e-form
15823Blepharoplasty, upper eyelid; with excessive skin weighting down lidYesYesNon-Covered BenefitOutpatient Surgery e-form
15830Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomyYesYesNon-Covered BenefitOutpatient Surgery e-form
15840Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)YesYesNon-Covered BenefitOutpatient Surgery e-form
15841Graft for facial nerve paralysis; free muscle graft (including obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15842Graft for facial nerve paralysis; free muscle flap by microsurgical techniqueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15845Graft for facial nerve paralysis; regional muscle transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15850Removal of sutures under anesthesia (other than local), same surgeonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15851Removal of sutures under anesthesia (other than local), other surgeonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15852Dressing change (for other than burns) under anesthesia (other than local)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15860Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15920Excision, coccygeal pressure ulcer, with coccygectomy; with primary sutureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15922Excision, coccygeal pressure ulcer, with coccygectomy; with flap closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15931Excision, sacral pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15933Excision, sacral pressure ulcer, with primary suture; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15934Excision, sacral pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15935Excision, sacral pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15936Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15937Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15940Excision, ischial pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15941Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15944Excision, ischial pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15945Excision, ischial pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15946Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15950Excision, trochanteric pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15951Excision, trochanteric pressure ulcer, with primary suture; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15952Excision, trochanteric pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15953Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15956Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15958Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
15999Unlisted procedure, excision pressure ulcerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16000Initial treatment, first degree burn, when no more than local treatment is requiredSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16020Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16025Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16030Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16035Escharotomy; initial incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
16036Escharotomy; each additional incision (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17000Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17003Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17004Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17106Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17107Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17108Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17110Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17111Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17250Chemical cauterization of granulation tissue (ie, proud flesh)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17260Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17261Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17262Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17263Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17264Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17266Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17270Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17271Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17272Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17273Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17274Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17276Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17280Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17281Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17282Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17283Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17284Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17286Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17311Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocksSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17312Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17313Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocksSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17314Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17315Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
17360Chemical exfoliation for acne (eg, acne paste, acid)YesYesNon-Covered BenefitOutpatient Surgery e-form
19000Puncture aspiration of cyst of breast;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19001Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19020Mastotomy with exploration or drainage of abscess, deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19030Injection procedure only for mammary ductogram or galactogramSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19081Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19082Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19083Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19084Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19085Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19086Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19100Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19101Biopsy of breast; open, incisionalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19105Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19110Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous ductSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19112Excision of lactiferous duct fistulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19120Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19125Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19126Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19281Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19282Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19283Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19284Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19285Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19286Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19287Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19288Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19294Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19296Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19297Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19298Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
19300Mastectomy for gynecomastiaSee CommentSee CommentNon-covered BenefitMust have diagnosis N62Outpatient Surgery e-form
19301Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);YesYesNon-covered BenefitBreast Reduction e-form
19302Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomyYesYesNon-covered BenefitBreast Reduction e-form
19303Mastectomy, simple, completeYesYesNon-covered BenefitBreast Reduction e-form
19305Mastectomy, radical, including pectoral muscles, axillary lymph nodesYesYesNon-covered BenefitBreast Reduction e-form
19306Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)YesYesNon-covered BenefitBreast Reduction e-form
19307Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscleYesYesNon-covered BenefitBreast Reduction e-form
19316MastopexyYesYesNon-covered BenefitBreast Reduction e-form
19318Breast reductionYesYesNon-covered BenefitBreast Reduction e-form
19325Breast augmentation with implantYesYesNon-covered BenefitBreast Reduction e-form
19328Removal of intact breast implantYesYesNon-covered BenefitBreast Reduction e-form
19330Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)YesYesNon-covered BenefitBreast Reduction e-form
19340Insertion of breast implant on same day of mastectomy (ie, immediate)YesYesNon-covered BenefitBreast Reduction e-form
19342Insertion or replacement of breast implant on separate day from mastectomyYesYesNon-covered BenefitBreast Reduction e-form
19350Nipple/areola reconstructionYesYesNon-covered BenefitBreast Reduction e-form
19355Correction of inverted nipplesYesYesNon-covered BenefitBreast Reduction e-form
19357Tissue expander placement in breast reconstruction, including subsequent expansion(s)YesYesNon-covered BenefitBreast Reduction e-form
19361Breast reconstruction; with latissimus dorsi flapYesYesNon-covered BenefitBreast Reduction e-form
19364Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)YesYesNon-covered BenefitBreast Reduction e-form
19367Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flapYesYesNon-covered BenefitBreast Reduction e-form
19368Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)YesYesNon-covered BenefitBreast Reduction e-form
19369Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flapYesYesNon-covered BenefitBreast Reduction e-form
19370Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomyYesYesNon-covered BenefitBreast Reduction e-form
19371Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contentsYesYesNon-covered BenefitBreast Reduction e-form
19380Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)YesYesNon-covered BenefitBreast Reduction e-form
19396Preparation of moulage for custom breast implantYesYesNon-covered BenefitBreast Reduction e-form
19499Unlisted procedure, breastYesYesNon-covered BenefitBreast Reduction e-form
20100Exploration of penetrating wound (separate procedure); neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20101Exploration of penetrating wound (separate procedure); chestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20102Exploration of penetrating wound (separate procedure); abdomen/flank/backSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20103Exploration of penetrating wound (separate procedure); extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20150Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20200Biopsy, muscle; superficialSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20205Biopsy, muscle; deepSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20206Biopsy, muscle, percutaneous needleSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20220Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20240Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20245Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20500Injection of sinus tract; therapeutic (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20501Injection of sinus tract; diagnostic (sinogram)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20520Removal of foreign body in muscle or tendon sheath; simpleSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20525Removal of foreign body in muscle or tendon sheath; deep or complicatedSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOut of Network e-form
20526Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20527Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20550Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20551Injection(s); single tendon origin/insertionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20552Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20553Injection(s); single or multiple trigger point(s), 3 or more musclesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20555Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20560Needle insertion(s) without injection(s); 1 or 2 muscle(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20561Needle insertion(s) without injection(s); 3 or more musclesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20600Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20604Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reportingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20605Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidanceSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20606Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reportingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20610Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20611Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reportingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20612Aspiration and/or injection of ganglion cyst(s) any locationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20615Aspiration and injection for treatment of bone cystSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20650Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20660Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20661Application of halo, including removal; cranialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20662Application of halo, including removal; pelvicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20663Application of halo, including removal; femoralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20664Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20665Removal of tongs or halo applied by another individualSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20670Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20680Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20690Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20692Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20693Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20694Removal, under anesthesia, of external fixation systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20696Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20697Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, removal and replacement) of strut, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20700Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20701Removal of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20702Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20703Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20704Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20705Removal of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20802Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20805Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20808Replantation, hand (includes hand through metacarpophalangeal joints), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20816Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20822Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20824Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20827Replantation, thumb (includes distal tip to MP joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20838Replantation, foot, complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20900Bone graft, any donor area; minor or small (eg, dowel or button)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20902Bone graft, any donor area; major or largeSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20910Cartilage graft; costochondralSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
20912Cartilage graft; nasal septumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20920Fascia lata graft; by stripperSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20922Fascia lata graft; by incision and area exposure, complex or sheetSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20924Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20930Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20931Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20932Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20933Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20934Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20936Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20937Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20938Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20939Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20950Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndromeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20955Bone graft with microvascular anastomosis; fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20956Bone graft with microvascular anastomosis; iliac crestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20957Bone graft with microvascular anastomosis; metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20962Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20969Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20970Free osteocutaneous flap with microvascular anastomosis; iliac crestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20972Free osteocutaneous flap with microvascular anastomosis; metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20973Free osteocutaneous flap with microvascular anastomosis; great toe with web spaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20974Electrical stimulation to aid bone healing; noninvasive (nonoperative)YesYesNon-Covered BenefitOutpatient Surgery e-form
20975Electrical stimulation to aid bone healing; invasive (operative)YesYesNon-Covered BenefitOutpatient Surgery e-form
20979Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20982Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequencySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20983Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20985Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
20999Unlisted procedure, musculoskeletal system, generalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21010Arthrotomy, temporomandibular jointYesYesNon-Covered BenefitOutpatient Surgery e-form
21011Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21012Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21013Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21014Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21015Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21016Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21025Excision of bone (eg, for osteomyelitis or bone abscess); mandibleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21026Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21029Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21030Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettageSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21031Excision of torus mandibularisSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21032Excision of maxillary torus palatinusSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21034Excision of malignant tumor of maxilla or zygomaSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21040Excision of benign tumor or cyst of mandible, by enucleation and/or curettageSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21044Excision of malignant tumor of mandibleSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21045Excision of malignant tumor of mandible; radical resectionSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21046Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21047Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21048Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21049Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21050Condylectomy, temporomandibular joint (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21060Meniscectomy, partial or complete, temporomandibular joint (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21070Coronoidectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21073Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21076Impression and custom preparation; surgical obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21077Impression and custom preparation; orbital prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21078Impression and custom preparation; interim obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21079Impression and custom preparation; definitive obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21080Impression and custom preparation; mandibular resection prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21081Impression and custom preparation; palatal augmentation prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21082Impression and custom preparation; palatal lift prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21083Impression and custom preparation; speech aid prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21084Impression and custom preparation; oral surgical splintYesYesNon-Covered BenefitOutpatient Surgery e-form
21085Impression and custom preparation; oral surgical splintSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21086Impression and custom preparation; auricular prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21087Impression and custom preparation; nasal prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21088Impression and custom preparation; facial prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-form
21089Unlisted maxillofacial prosthetic procedureYesYesNon-Covered BenefitOutpatient Surgery e-form
21100Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21110Application of interdental fixation device for conditions other than fracture or dislocation, includes removalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21116Injection procedure for temporomandibular joint arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21120Genioplasty; augmentation (autograft, allograft, prosthetic material)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21121Genioplasty; sliding osteotomy, single pieceSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21122Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21123Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21125Augmentation, mandibular body or angle; prosthetic materialSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21127Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21137Reduction forehead; contouring onlySee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21138Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21139Reduction forehead; contouring and setback of anterior frontal sinus wallSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21141Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graftSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21142Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graftSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21143Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graftSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21145Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21146Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21147Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21150Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21151Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21154Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort ISee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21155Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort ISee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21159Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort ISee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21160Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort ISee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21172Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21175Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21179Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21180Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21181Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranialSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21182Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21183Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21184Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cmSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21188Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21193Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graftSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21194Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21195Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21196Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21198Osteotomy, mandible, segmental;See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21199Osteotomy, mandible, segmental; with genioglossus advancementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21206Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21208Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21209Osteoplasty, facial bones; reductionSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21210Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21215Graft, bone; mandible (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21230Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21235Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21240Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21242Arthroplasty, temporomandibular joint, with allograftSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21243Arthroplasty, temporomandibular joint, with prosthetic joint replacementSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21244Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21245Reconstruction of mandible or maxilla, subperiosteal implant; partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21246Reconstruction of mandible or maxilla, subperiosteal implant; completeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21247Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21248Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21249Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); completeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21255Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21256Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21260Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21261Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approachSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21263Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancementSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21267Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approachSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21268Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approachSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21270Malar augmentation, prosthetic materialSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21275Secondary revision of orbitocraniofacial reconstructionSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21280Medial canthopexy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21282Lateral canthopexySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21295Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21296Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21299Unlisted craniofacial and maxillofacial procedureSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21310Closed treatment of nasal bone fracture without manipulationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21315Closed treatment of nasal bone fracture; without stabilizationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21320Closed treatment of nasal bone fracture; with stabilizationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21325Open treatment of nasal fracture; uncomplicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21330Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21335Open treatment of nasal fracture; with concomitant open treatment of fractured septumSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21336Open treatment of nasal septal fracture, with or without stabilizationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21337Closed treatment of nasal septal fracture, with or without stabilizationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21338Open treatment of nasoethmoid fracture; without external fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21339Open treatment of nasoethmoid fracture; with external fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21340Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatusSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21343Open treatment of depressed frontal sinus fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21344Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approachesSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21345Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splintSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21346Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21347Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approachesSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21348Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21355Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21356Open treatment of depressed zygomatic arch fracture (eg, Gillies approach)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21360Open treatment of depressed malar fracture, including zygomatic arch and malar tripodSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21365Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approachesSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21366Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21385Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21386Open treatment of orbital floor blowout fracture; periorbital approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21387Open treatment of orbital floor blowout fracture; combined approachSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21390Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21395Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21400Closed treatment of fracture of orbit, except blowout; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21401Closed treatment of fracture of orbit, except blowout; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21406Open treatment of fracture of orbit, except blowout; without implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21407Open treatment of fracture of orbit, except blowout; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21408Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21421Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splintSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21422Open treatment of palatal or maxillary fracture (LeFort I type);See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21423Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approachesSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21431Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splintSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21432Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21433Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approachesSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21435Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21436Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21440Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21445Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21450Closed treatment of mandibular fracture; without manipulationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21451Closed treatment of mandibular fracture; with manipulationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21452Percutaneous treatment of mandibular fracture, with external fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21453Closed treatment of mandibular fracture with interdental fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21454Open treatment of mandibular fracture with external fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21462Open treatment of mandibular fracture; with interdental fixationSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21465Open treatment of mandibular condylar fractureSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21470Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splintsSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21480Closed treatment of temporomandibular dislocation; initial or subsequentSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21485Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequentSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21497Interdental wiring, for condition other than fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21499Unlisted musculoskeletal procedure, headSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
21501Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21502Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21510Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21550Biopsy, soft tissue of neck or thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21552Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21554Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21555Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21556Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21557Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21558Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21600Excision of rib, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21601Excision of chest wall tumor including rib(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21602Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21603Excision of chest wall tumor involving rib(s), with plastic reconstruction; with mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21610Costotransversectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21615Excision first and/or cervical rib;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21616Excision first and/or cervical rib; with sympathectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21620Ostectomy of sternum, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21627Sternal debridementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21630Radical resection of sternum;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21632Radical resection of sternum; with mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21685Hyoid myotomy and suspensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21700Division of scalenus anticus; without resection of cervical ribSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21705Division of scalenus anticus; with resection of cervical ribSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21720Division of sternocleidomastoid for torticollis, open operation; without cast applicationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21725Division of sternocleidomastoid for torticollis, open operation; with cast applicationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21740Reconstructive repair of pectus excavatum or carinatum; openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21742Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21743Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21750Closure of median sternotomy separation with or without debridement (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21811Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21812Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21813Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21820Closed treatment of sternum fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21825Open treatment of sternum fracture with or without skeletal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21899Unlisted procedure, neck or thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21920Biopsy, soft tissue of back or flank; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21925Biopsy, soft tissue of back or flank; deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21930Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21931Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21932Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21933Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21935Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
21936Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22010Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22015Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22100Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22101Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22102Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22103Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22110Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22112Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22114Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22116Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22206Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22207Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22208Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22210Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22212Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22214Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22216Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22220Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22222Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22224Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22226Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22310Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22315Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22318Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without graftingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22319Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with graftingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22325Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22326Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22327Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22328Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22505Manipulation of spine requiring anesthesia, any regionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22510Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22511Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22512Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22513Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracicYesYesNon-Covered BenefitOutpatient Surgery e-form
22514Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbarYesYesNon-Covered BenefitOutpatient Surgery e-form
22515Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-form
22526Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single levelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22527Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-form
22532Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22533Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22534Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22548Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid processSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22551Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22552Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22554Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22556Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22558Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22585Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22586Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22590Arthrodesis, posterior technique, craniocervical (occiput-C2)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22595Arthrodesis, posterior technique, atlas-axis (C1-C2)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segmentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22610Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22612Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22614Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22630Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22632Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22633Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbarYesYesNon-Covered BenefitOutpatient Surgery e-form
22634Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-form
22800Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22802Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22804Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22808Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22810Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22812Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22818Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22819Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22830Exploration of spinal fusionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22840Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22841Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22842Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22843Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22844Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22845Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22846Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22847Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22848Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22849Reinsertion of spinal fixation deviceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22850Removal of posterior nonsegmental instrumentation (eg, Harrington rod)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22852Removal of posterior segmental instrumentationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22853Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22854Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22855Removal of anterior instrumentationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22856Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22857Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22858Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22859Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22861Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22862Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22864Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22865Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22867Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single levelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22868Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22869Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single levelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22870Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22899Unlisted procedure, spineSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22900Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22901Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22902Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22903Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22904Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22905Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
22999Unlisted procedure, abdomen, musculoskeletal systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23000Removal of subdeltoid calcareous deposits, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23020Capsular contracture release (eg, Sever type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23030Incision and drainage, shoulder area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23031Incision and drainage, shoulder area; infected bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23035Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23040Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23044Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23065Biopsy, soft tissue of shoulder area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23066Biopsy, soft tissue of shoulder area; deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23071Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23073Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23075Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23076Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23077Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23078Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23100Arthrotomy, glenohumeral joint, including biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23101Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23105Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23106Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23107Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23120Claviculectomy; partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23125Claviculectomy; totalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23130Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament releaseSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23140Excision or curettage of bone cyst or benign tumor of clavicle or scapula;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23145Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23146Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23150Excision or curettage of bone cyst or benign tumor of proximal humerus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23155Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23156Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23170Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23172Sequestrectomy (eg, for osteomyelitis or bone abscess), scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23174Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23180Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23182Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23184Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23190Ostectomy of scapula, partial (eg, superior medial angle)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23195Resection, humeral headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23200Radical resection of tumor; clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23210Radical resection of tumor; scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23220Radical resection of tumor, proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23330Removal of foreign body, shoulder; subcutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23333Removal of foreign body, shoulder; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23334Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23335Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23350Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23395Muscle transfer, any type, shoulder or upper arm; singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23397Muscle transfer, any type, shoulder or upper arm; multipleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23400Scapulopexy (eg, Sprengels deformity or for paralysis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23405Tenotomy, shoulder area; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23406Tenotomy, shoulder area; multiple tendons through same incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23410Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acuteSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23412Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23415Coracoacromial ligament release, with or without acromioplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23420Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23430Tenodesis of long tendon of bicepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23440Resection or transplantation of long tendon of bicepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23450Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23455Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23460Capsulorrhaphy, anterior, any type; with bone blockSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23462Capsulorrhaphy, anterior, any type; with coracoid process transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23465Capsulorrhaphy, glenohumeral joint, posterior, with or without bone blockSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23466Capsulorrhaphy, glenohumeral joint, any type multi-directional instabilitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23470Arthroplasty, glenohumeral joint; hemiarthroplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23472Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23473Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23474Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23480Osteotomy, clavicle, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23485Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23490Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23491Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23500Closed treatment of clavicular fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23505Closed treatment of clavicular fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23515Open treatment of clavicular fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23520Closed treatment of sternoclavicular dislocation; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23525Closed treatment of sternoclavicular dislocation; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23530Open treatment of sternoclavicular dislocation, acute or chronic;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23532Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23540Closed treatment of acromioclavicular dislocation; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23545Closed treatment of acromioclavicular dislocation; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23550Open treatment of acromioclavicular dislocation, acute or chronic;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23552Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23570Closed treatment of scapular fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23575Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23585Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23600Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23605Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23615Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23616Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23620Closed treatment of greater humeral tuberosity fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23625Closed treatment of greater humeral tuberosity fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23630Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23650Closed treatment of shoulder dislocation, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23655Closed treatment of shoulder dislocation, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23660Open treatment of acute shoulder dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23665Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23670Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23675Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23680Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23700Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23800Arthrodesis, glenohumeral joint;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23802Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23900Interthoracoscapular amputation (forequarter)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23920Disarticulation of shoulder;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23921Disarticulation of shoulder; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23929Unlisted procedure, shoulderSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23930Incision and drainage, upper arm or elbow area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23931Incision and drainage, upper arm or elbow area; bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
23935Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24000Arthrotomy, elbow, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24006Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24065Biopsy, soft tissue of upper arm or elbow area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24066Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24071Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24073Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24075Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24076Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24077Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24079Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24100Arthrotomy, elbow; with synovial biopsy onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24101Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24102Arthrotomy, elbow; with synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24105Excision, olecranon bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24110Excision or curettage of bone cyst or benign tumor, humerus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24115Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24116Excision or curettage of bone cyst or benign tumor, humerus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24120Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24125Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24126Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24130Excision, radial headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24134Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24136Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24138Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon processSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24140Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24145Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24147Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon processSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24149Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24150Radical resection of tumor, shaft or distal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24152Radical resection of tumor, radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24155Resection of elbow joint (arthrectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24160Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar componentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24164Removal of prosthesis, includes debridement and synovectomy when performed; radial headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24200Removal of foreign body, upper arm or elbow area; subcutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24201Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24220Injection procedure for elbow arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24300Manipulation, elbow, under anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24301Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24305Tendon lengthening, upper arm or elbow, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24310Tenotomy, open, elbow to shoulder, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24320Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24330Flexor-plasty, elbow (eg, Steindler type advancement);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24331Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24332Tenolysis, tricepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24340Tenodesis of biceps tendon at elbow (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24341Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24342Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24343Repair lateral collateral ligament, elbow, with local tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24344Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24345Repair medial collateral ligament, elbow, with local tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24346Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24357Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24358Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24359Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachmentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24360Arthroplasty, elbow; with membrane (eg, fascial)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24361Arthroplasty, elbow; with distal humeral prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24362Arthroplasty, elbow; with implant and fascia lata ligament reconstructionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24363Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24365Arthroplasty, radial head;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24366Arthroplasty, radial head; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24370Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24371Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24400Osteotomy, humerus, with or without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24410Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24420Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24430Repair of nonunion or malunion, humerus; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24435Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24470Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24495Decompression fasciotomy, forearm, with brachial artery explorationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24498Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24500Closed treatment of humeral shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24505Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24515Open treatment of humeral shaft fracture with plate/screws, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24516Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screwsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24530Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24535Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24538Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24545Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24546Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24560Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24565Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24566Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24575Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24576Closed treatment of humeral condylar fracture, medial or lateral; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24577Closed treatment of humeral condylar fracture, medial or lateral; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24579Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24582Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24586Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24587Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24600Treatment of closed elbow dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24605Treatment of closed elbow dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24615Open treatment of acute or chronic elbow dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24620Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24635Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24640Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24650Closed treatment of radial head or neck fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24655Closed treatment of radial head or neck fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24665Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24666Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24670Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24675Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24685Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24800Arthrodesis, elbow joint; localSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24802Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24900Amputation, arm through humerus; with primary closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24920Amputation, arm through humerus; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24925Amputation, arm through humerus; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24930Amputation, arm through humerus; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24931Amputation, arm through humerus; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24935Stump elongation, upper extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24940Cineplasty, upper extremity, complete procedureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
24999Unlisted procedure, humerus or elbowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25000Incision, extensor tendon sheath, wrist (eg, deQuervains disease)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25001Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25020Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25023Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25024Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25025Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25028Incision and drainage, forearm and/or wrist; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25031Incision and drainage, forearm and/or wrist; bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25035Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25040Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25065Biopsy, soft tissue of forearm and/or wrist; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25066Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25071Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25073Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25075Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25076Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25077Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25078Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25085Capsulotomy, wrist (eg, contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25100Arthrotomy, wrist joint; with biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25101Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25105Arthrotomy, wrist joint; with synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25107Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complexSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25109Excision of tendon, forearm and/or wrist, flexor or extensor, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25110Excision, lesion of tendon sheath, forearm and/or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25111Excision of ganglion, wrist (dorsal or volar); primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25112Excision of ganglion, wrist (dorsal or volar); recurrentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25115Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexorsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25116Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25118Synovectomy, extensor tendon sheath, wrist, single compartment;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25119Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25120Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25125Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25126Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25130Excision or curettage of bone cyst or benign tumor of carpal bones;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25135Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25136Excision or curettage of bone cyst or benign tumor of carpal bones; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25145Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25150Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25151Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25170Radical resection of tumor, radius or ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25210Carpectomy; 1 boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25215Carpectomy; all bones of proximal rowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25230Radial styloidectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25240Excision distal ulna partial or complete (eg, Darrach type or matched resection)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25246Injection procedure for wrist arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25248Exploration with removal of deep foreign body, forearm or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25250Removal of wrist prosthesis; (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25251Removal of wrist prosthesis; complicated, including total wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25259Manipulation, wrist, under anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25260Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25263Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25265Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25270Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25272Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25274Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25275Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25280Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25290Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25295Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25300Tenodesis at wrist; flexors of fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25301Tenodesis at wrist; extensors of fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25310Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25312Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25315Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25316Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25320Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instabilitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25332Arthroplasty, wrist, with or without interposition, with or without external or internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25335Centralization of wrist on ulna (eg, radial club hand)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25337Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25350Osteotomy, radius; distal thirdSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25355Osteotomy, radius; middle or proximal thirdSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25360Osteotomy; ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25365Osteotomy; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25370Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25375Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25390Osteoplasty, radius OR ulna; shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25391Osteoplasty, radius OR ulna; lengthening with autograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25392Osteoplasty, radius AND ulna; shortening (excluding 64876)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25393Osteoplasty, radius AND ulna; lengthening with autograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25394Osteoplasty, carpal bone, shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25400Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25405Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25415Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25420Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25425Repair of defect with autograft; radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25426Repair of defect with autograft; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25430Insertion of vascular pedicle into carpal bone (eg, Hori procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25431Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25440Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25441Arthroplasty with prosthetic replacement; distal radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25442Arthroplasty with prosthetic replacement; distal ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25443Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25444Arthroplasty with prosthetic replacement; lunateSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25445Arthroplasty with prosthetic replacement; trapeziumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25446Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25447Arthroplasty, interposition, intercarpal or carpometacarpal jointsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25449Revision of arthroplasty, including removal of implant, wrist jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25450Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25455Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25490Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25491Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25492Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25500Closed treatment of radial shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25505Closed treatment of radial shaft fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25515Open treatment of radial shaft fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25520Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25525Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25526Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complexSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25530Closed treatment of ulnar shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25535Closed treatment of ulnar shaft fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25545Open treatment of ulnar shaft fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25560Closed treatment of radial and ulnar shaft fractures; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25565Closed treatment of radial and ulnar shaft fractures; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25574Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25575Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25600Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25605Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25606Percutaneous skeletal fixation of distal radial fracture or epiphyseal separationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25607Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25608Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25609Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25622Closed treatment of carpal scaphoid (navicular) fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25624Closed treatment of carpal scaphoid (navicular) fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25628Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25630Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25635Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25645Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25650Closed treatment of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25651Percutaneous skeletal fixation of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25652Open treatment of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25660Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25670Open treatment of radiocarpal or intercarpal dislocation, 1 or more bonesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25671Percutaneous skeletal fixation of distal radioulnar dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25675Closed treatment of distal radioulnar dislocation with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25676Open treatment of distal radioulnar dislocation, acute or chronicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25680Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25685Open treatment of trans-scaphoperilunar type of fracture dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25690Closed treatment of lunate dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25695Open treatment of lunate dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25800Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25805Arthrodesis, wrist; with sliding graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25810Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25820Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25825Arthrodesis, wrist; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25830Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25900Amputation, forearm, through radius and ulna;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25905Amputation, forearm, through radius and ulna; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25907Amputation, forearm, through radius and ulna; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25909Amputation, forearm, through radius and ulna; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25915Krukenberg procedureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25920Disarticulation through wrist;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25922Disarticulation through wrist; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25924Disarticulation through wrist; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25927Transmetacarpal amputation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25929Transmetacarpal amputation; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25931Transmetacarpal amputation; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
25999Unlisted procedure, forearm or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26010Drainage of finger abscess; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26011Drainage of finger abscess; complicated (eg, felon)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26020Drainage of tendon sheath, digit and/or palm, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26025Drainage of palmar bursa; single, bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26030Drainage of palmar bursa; multiple bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26034Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26035Decompression fingers and/or hand, injection injury (eg, grease gun)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26037Decompressive fasciotomy, hand (excludes 26035)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26040Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26045Fasciotomy, palmar (eg, Dupuytren's contracture); open, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26055Tendon sheath incision (eg, for trigger finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26060Tenotomy, percutaneous, single, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26070Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26075Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26080Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26100Arthrotomy with biopsy; carpometacarpal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26105Arthrotomy with biopsy; metacarpophalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26110Arthrotomy with biopsy; interphalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26111Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26113Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); 1.5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26115Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26116Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26117Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26118Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26121Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26123Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26125Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26130Synovectomy, carpometacarpal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26135Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26140Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26145Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26160Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26170Excision of tendon, palm, flexor or extensor, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26180Excision of tendon, finger, flexor or extensor, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26185Sesamoidectomy, thumb or finger (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26200Excision or curettage of bone cyst or benign tumor of metacarpal;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26205Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26210Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26215Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26230Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26235Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26236Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26250Radical resection of tumor, metacarpalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26260Radical resection of tumor, proximal or middle phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26262Radical resection of tumor, distal phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26320Removal of implant from finger or handSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26340Manipulation, finger joint, under anesthesia, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26341Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cordSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26350Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26352Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26356Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26357Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26358Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26370Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26372Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26373Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26390Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26392Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26410Repair, extensor tendon, hand, primary or secondary; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26412Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26415Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26416Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26418Repair, extensor tendon, finger, primary or secondary; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26420Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26426Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26428Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26432Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26433Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26434Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26437Realignment of extensor tendon, hand, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26440Tenolysis, flexor tendon; palm OR finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26442Tenolysis, flexor tendon; palm AND finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26445Tenolysis, extensor tendon, hand OR finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26449Tenolysis, complex, extensor tendon, finger, including forearm, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26450Tenotomy, flexor, palm, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26455Tenotomy, flexor, finger, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26460Tenotomy, extensor, hand or finger, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26471Tenodesis; of proximal interphalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26474Tenodesis; of distal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26476Lengthening of tendon, extensor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26477Shortening of tendon, extensor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26478Lengthening of tendon, flexor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26479Shortening of tendon, flexor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26480Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26483Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26485Transfer or transplant of tendon, palmar; without free tendon graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26489Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26490Opponensplasty; superficialis tendon transfer type, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26492Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26494Opponensplasty; hypothenar muscle transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26496Opponensplasty; other methodsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26497Transfer of tendon to restore intrinsic function; ring and small fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26498Transfer of tendon to restore intrinsic function; all 4 fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26499Correction claw finger, other methodsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26500Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26502Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26508Release of thenar muscle(s) (eg, thumb contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26510Cross intrinsic transfer, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26516Capsulodesis, metacarpophalangeal joint; single digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26517Capsulodesis, metacarpophalangeal joint; 2 digitsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26518Capsulodesis, metacarpophalangeal joint; 3 or 4 digitsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26520Capsulectomy or capsulotomy; metacarpophalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26525Capsulectomy or capsulotomy; interphalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26530Arthroplasty, metacarpophalangeal joint; each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26531Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26535Arthroplasty, interphalangeal joint; each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26536Arthroplasty, interphalangeal joint; with prosthetic implant, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26540Repair of collateral ligament, metacarpophalangeal or interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26541Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26542Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26545Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26546Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26548Repair and reconstruction, finger, volar plate, interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26550Pollicization of a digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26551Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26553Transfer, toe-to-hand with microvascular anastomosis; other than great toe, singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26554Transfer, toe-to-hand with microvascular anastomosis; other than great toe, doubleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26555Transfer, finger to another position without microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26556Transfer, free toe joint, with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26560Repair of syndactyly (web finger) each web space; with skin flapsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26561Repair of syndactyly (web finger) each web space; with skin flaps and graftsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26562Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26565Osteotomy; metacarpal, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26567Osteotomy; phalanx of finger, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26568Osteoplasty, lengthening, metacarpal or phalanxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26580Repair cleft handSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26587Reconstruction of polydactylous digit, soft tissue and boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26590Repair macrodactylia, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26591Repair, intrinsic muscles of hand, each muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26593Release, intrinsic muscles of hand, each muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26596Excision of constricting ring of finger, with multiple Z-plastiesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26600Closed treatment of metacarpal fracture, single; without manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26605Closed treatment of metacarpal fracture, single; with manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26607Closed treatment of metacarpal fracture, with manipulation, with external fixation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26608Percutaneous skeletal fixation of metacarpal fracture, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26615Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26641Closed treatment of carpometacarpal dislocation, thumb, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26645Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26650Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26665Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26670Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26675Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26676Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26685Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26686Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reductionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26700Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26705Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26706Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26715Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26720Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26725Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26727Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26735Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26740Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26742Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26746Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26750Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26755Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26756Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26765Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26770Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26775Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26776Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26785Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26820Fusion in opposition, thumb, with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26841Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26842Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26843Arthrodesis, carpometacarpal joint, digit, other than thumb, each;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26844Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26850Arthrodesis, metacarpophalangeal joint, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26852Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26860Arthrodesis, interphalangeal joint, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26861Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26862Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26863Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26910Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26951Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26952Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26989Unlisted procedure, hands or fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26990Incision and drainage, pelvis or hip joint area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26991Incision and drainage, pelvis or hip joint area; infected bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
26992Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27000Tenotomy, adductor of hip, percutaneous (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27001Tenotomy, adductor of hip, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27003Tenotomy, adductor, subcutaneous, open, with obturator neurectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27005Tenotomy, hip flexor(s), open (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27006Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27025Fasciotomy, hip or thigh, any typeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27027Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27030Arthrotomy, hip, with drainage (eg, infection)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27033Arthrotomy, hip, including exploration or removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27035Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nervesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27036Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27040Biopsy, soft tissue of pelvis and hip area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27041Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscularSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27043Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27045Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27047Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27048Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27049Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27050Arthrotomy, with biopsy; sacroiliac jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27052Arthrotomy, with biopsy; hip jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27054Arthrotomy with synovectomy, hip jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27057Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27059Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27060Excision; ischial bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27062Excision; trochanteric bursa or calcificationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27065Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27066Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27067Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27070Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27071Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27075Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27076Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27077Radical resection of tumor; innominate bone, totalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27078Radical resection of tumor; ischial tuberosity and greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27080Coccygectomy, primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27086Removal of foreign body, pelvis or hip; subcutaneous tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27087Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27090Removal of hip prosthesis; (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27091Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27093Injection procedure for hip arthrography; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27095Injection procedure for hip arthrography; with anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27096Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performedYesYesNon-covered BenefitPain Managament Request e-form
27097Release or recession, hamstring, proximalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27098Transfer, adductor to ischiumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27100Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27105Transfer paraspinal muscle to hip (includes fascial or tendon extension graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27110Transfer iliopsoas; to greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27111Transfer iliopsoas; to femoral neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27120Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27122Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27125Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27132Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27134Revision of total hip arthroplasty; both components, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27137Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27138Revision of total hip arthroplasty; femoral component only, with or without allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27140Osteotomy and transfer of greater trochanter of femur (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27146Osteotomy, iliac, acetabular or innominate bone;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27147Osteotomy, iliac, acetabular or innominate bone; with open reduction of hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27151Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27156Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27158Osteotomy, pelvis, bilateral (eg, congenital malformation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27161Osteotomy, femoral neck (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27165Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27170Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27175Treatment of slipped femoral epiphysis; by traction, without reductionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27176Treatment of slipped femoral epiphysis; by single or multiple pinning, in situSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27177Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27178Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27179Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27181Open treatment of slipped femoral epiphysis; osteotomy and internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27185Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27187Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27197Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27198Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27200Closed treatment of coccygeal fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27202Open treatment of coccygeal fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27215Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27216Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27217Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27218Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27220Closed treatment of acetabulum (hip socket) fracture(s); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27222Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27226Open treatment of posterior or anterior acetabular wall fracture, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27227Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27228Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27230Closed treatment of femoral fracture, proximal end, neck; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27232Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27235Percutaneous skeletal fixation of femoral fracture, proximal end, neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27236Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27238Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27240Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27244Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27245Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27246Closed treatment of greater trochanteric fracture, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27248Open treatment of greater trochanteric fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27250Closed treatment of hip dislocation, traumatic; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27252Closed treatment of hip dislocation, traumatic; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27253Open treatment of hip dislocation, traumatic, without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27254Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27256Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27257Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27258Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27259Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27265Closed treatment of post hip arthroplasty dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27266Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27267Closed treatment of femoral fracture, proximal end, head; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27268Closed treatment of femoral fracture, proximal end, head; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27269Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27275Manipulation, hip joint, requiring general anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27279Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing deviceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27280Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27282Arthrodesis, symphysis pubis (including obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27284Arthrodesis, hip joint (including obtaining graft);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27286Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27290Interpelviabdominal amputation (hindquarter amputation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27295Disarticulation of hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27299Unlisted procedure, pelvis or hip jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27301Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee regionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27303Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27305Fasciotomy, iliotibial (tenotomy), openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27306Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27307Tenotomy, percutaneous, adductor or hamstring; multiple tendonsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27310Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27323Biopsy, soft tissue of thigh or knee area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27324Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27325Neurectomy, hamstring muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27326Neurectomy, popliteal (gastrocnemius)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27327Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27328Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27329Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27330Arthrotomy, knee; with synovial biopsy onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27331Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodiesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27332Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27333Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27334Arthrotomy, with synovectomy, knee; anterior OR posteriorSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27335Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27337Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27339Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27340Excision, prepatellar bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27345Excision of synovial cyst of popliteal space (eg, Baker's cyst)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27347Excision of lesion of meniscus or capsule (eg, cyst, ganglion), kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27350Patellectomy or hemipatellectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27355Excision or curettage of bone cyst or benign tumor of femur;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27356Excision or curettage of bone cyst or benign tumor of femur; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27357Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27358Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27360Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27364Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27365Radical resection of tumor, femur or kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27369Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27372Removal of foreign body, deep, thigh region or knee areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27380Suture of infrapatellar tendon; primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27381Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27385Suture of quadriceps or hamstring muscle rupture; primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27386Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27390Tenotomy, open, hamstring, knee to hip; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27391Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 legSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27392Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27393Lengthening of hamstring tendon; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27394Lengthening of hamstring tendon; multiple tendons, 1 legSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27395Lengthening of hamstring tendon; multiple tendons, bilateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27396Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27397Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); multiple tendonsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27400Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27403Arthrotomy with meniscus repair, kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27405Repair, primary, torn ligament and/or capsule, knee; collateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27407Repair, primary, torn ligament and/or capsule, knee; cruciateSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27409Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligamentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27412Autologous chondrocyte implantation, kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27415Osteochondral allograft, knee, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27416Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27418Anterior tibial tubercleplasty (eg, Maquet type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27420Reconstruction of dislocating patella; (eg, Hauser type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27422Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27424Reconstruction of dislocating patella; with patellectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27425Lateral retinacular release, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27427Ligamentous reconstruction (augmentation), knee; extra-articularSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27428Ligamentous reconstruction (augmentation), knee; intra-articular (open)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27429Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articularSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27430Quadricepsplasty (eg, Bennett or Thompson type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27435Capsulotomy, posterior capsular release, kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27437Arthroplasty, patella; without prosthesisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27438Arthroplasty, patella; with prosthesisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27440Arthroplasty, knee, tibial plateau;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27441Arthroplasty, knee, tibial plateau; with debridement and partial synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27442Arthroplasty, femoral condyles or tibial plateau(s), knee;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27443Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27445Arthroplasty, knee, hinge prosthesis (eg, Walldius type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27446Arthroplasty, knee, condyle and plateau; medial OR lateral compartmentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27447Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27448Osteotomy, femur, shaft or supracondylar; without fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27450Osteotomy, femur, shaft or supracondylar; with fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27454Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27455Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); before epiphyseal closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27457Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27465Osteoplasty, femur; shortening (excluding 64876)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27466Osteoplasty, femur; lengtheningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27468Osteoplasty, femur; combined, lengthening and shortening with femoral segment transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27470Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27472Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27475Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27477Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, proximalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27479Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27485Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27486Revision of total knee arthroplasty, with or without allograft; 1 componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27487Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27488Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27495Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27496Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27497Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27498Decompression fasciotomy, thigh and/or knee, multiple compartments;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27499Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27500Closed treatment of femoral shaft fracture, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27501Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27502Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27503Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27506Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screwsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27507Open treatment of femoral shaft fracture with plate/screws, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27508Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27509Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27510Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27511Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27513Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27514Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27516Closed treatment of distal femoral epiphyseal separation; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27517Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27519Open treatment of distal femoral epiphyseal separation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27520Closed treatment of patellar fracture, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27524Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27530Closed treatment of tibial fracture, proximal (plateau); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27532Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27535Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27536Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27538Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27540Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27550Closed treatment of knee dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27552Closed treatment of knee dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27556Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstructionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27557Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27558Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair, with augmentation/reconstructionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27560Closed treatment of patellar dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27562Closed treatment of patellar dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27566Open treatment of patellar dislocation, with or without partial or total patellectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27570Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27580Arthrodesis, knee, any techniqueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27590Amputation, thigh, through femur, any level;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27591Amputation, thigh, through femur, any level; immediate fitting technique including first castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27592Amputation, thigh, through femur, any level; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27594Amputation, thigh, through femur, any level; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27596Amputation, thigh, through femur, any level; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27598Disarticulation at kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27599Unlisted procedure, femur or kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27600Decompression fasciotomy, leg; anterior and/or lateral compartments onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27601Decompression fasciotomy, leg; posterior compartment(s) onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27602Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27603Incision and drainage, leg or ankle; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27604Incision and drainage, leg or ankle; infected bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27605Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27606Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27607Incision (eg, osteomyelitis or bone abscess), leg or ankleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27610Arthrotomy, ankle, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27612Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengtheningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27613Biopsy, soft tissue of leg or ankle area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27614Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27615Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27616Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27618Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27619Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27620Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27625Arthrotomy, with synovectomy, ankle;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27626Arthrotomy, with synovectomy, ankle; including tenosynovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27630Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27632Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27634Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27635Excision or curettage of bone cyst or benign tumor, tibia or fibula;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27637Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27638Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27640Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27641Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27645Radical resection of tumor; tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27646Radical resection of tumor; fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27647Radical resection of tumor; talus or calcaneusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27648Injection procedure for ankle arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27650Repair, primary, open or percutaneous, ruptured Achilles tendon;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27652Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27654Repair, secondary, Achilles tendon, with or without graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27656Repair, fascial defect of legSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27658Repair, flexor tendon, leg; primary, without graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27659Repair, flexor tendon, leg; secondary, with or without graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27664Repair, extensor tendon, leg; primary, without graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27665Repair, extensor tendon, leg; secondary, with or without graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27675Repair, dislocating peroneal tendons; without fibular osteotomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27676Repair, dislocating peroneal tendons; with fibular osteotomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27680Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27681Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27685Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27686Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27687Gastrocnemius recession (eg, Strayer procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27690Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27691Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27692Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27695Repair, primary, disrupted ligament, ankle; collateralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27696Repair, primary, disrupted ligament, ankle; both collateral ligamentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27698Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27700Arthroplasty, ankle;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27702Arthroplasty, ankle; with implant (total ankle)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27703Arthroplasty, ankle; revision, total ankleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27704Removal of ankle implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27705Osteotomy; tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27707Osteotomy; fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27709Osteotomy; tibia and fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27712Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27715Osteoplasty, tibia and fibula, lengthening or shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27720Repair of nonunion or malunion, tibia; without graft, (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27722Repair of nonunion or malunion, tibia; with sliding graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27724Repair of nonunion or malunion, tibia; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27725Repair of nonunion or malunion, tibia; by synostosis, with fibula, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27726Repair of fibula nonunion and/or malunion with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27727Repair of congenital pseudarthrosis, tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27730Arrest, epiphyseal (epiphysiodesis), open; distal tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27732Arrest, epiphyseal (epiphysiodesis), open; distal fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27734Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27740Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27742Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27745Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27750Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27752Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27756Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27758Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27759Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27760Closed treatment of medial malleolus fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27762Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27766Open treatment of medial malleolus fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27767Closed treatment of posterior malleolus fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27768Closed treatment of posterior malleolus fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27769Open treatment of posterior malleolus fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27780Closed treatment of proximal fibula or shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27781Closed treatment of proximal fibula or shaft fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27784Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27786Closed treatment of distal fibular fracture (lateral malleolus); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27788Closed treatment of distal fibular fracture (lateral malleolus); with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27792Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27808Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27810Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27814Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27816Closed treatment of trimalleolar ankle fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27818Closed treatment of trimalleolar ankle fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27822Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27823Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27824Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27825Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27826Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27827Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of tibia onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27828Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27829Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27830Closed treatment of proximal tibiofibular joint dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27831Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27832Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27840Closed treatment of ankle dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27842Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27846Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27848Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27860Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27870Arthrodesis, ankle, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27871Arthrodesis, tibiofibular joint, proximal or distalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27880Amputation, leg, through tibia and fibula;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27881Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27882Amputation, leg, through tibia and fibula; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27884Amputation, leg, through tibia and fibula; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27886Amputation, leg, through tibia and fibula; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27888Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nervesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27889Ankle disarticulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27892Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27893Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27894Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
27899Unlisted procedure, leg or ankleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28001Incision and drainage, bursa, footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28002Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal spaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28003Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areasSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28005Incision, bone cortex (eg, osteomyelitis or bone abscess), footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28008Fasciotomy, foot and/or toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28010Tenotomy, percutaneous, toe; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28011Tenotomy, percutaneous, toe; multiple tendonsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28020Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28022Arthrotomy, including exploration, drainage, or removal of loose or foreign body; metatarsophalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28024Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28035Release, tarsal tunnel (posterior tibial nerve decompression)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28039Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28041Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); 1.5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28043Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28045Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); less than 1.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28046Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28047Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28050Arthrotomy with biopsy; intertarsal or tarsometatarsal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28052Arthrotomy with biopsy; metatarsophalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28054Arthrotomy with biopsy; interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28055Neurectomy, intrinsic musculature of footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28060Fasciectomy, plantar fascia; partial (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28062Fasciectomy, plantar fascia; radical (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28070Synovectomy; intertarsal or tarsometatarsal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28072Synovectomy; metatarsophalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28080Excision, interdigital (Morton) neuroma, single, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28086Synovectomy, tendon sheath, foot; flexorSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28088Synovectomy, tendon sheath, foot; extensorSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28090Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28092Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28100Excision or curettage of bone cyst or benign tumor, talus or calcaneus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28102Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28103Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28104Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28106Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28107Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28108Excision or curettage of bone cyst or benign tumor, phalanges of footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28110Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28111Ostectomy, complete excision; first metatarsal headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28112Ostectomy, complete excision; other metatarsal head (second, third or fourth)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28113Ostectomy, complete excision; fifth metatarsal headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28114Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28116Ostectomy, excision of tarsal coalitionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28118Ostectomy, calcaneus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28119Ostectomy, calcaneus; for spur, with or without plantar fascial releaseSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28120Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28122Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28124Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28126Resection, partial or complete, phalangeal base, each toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28130Talectomy (astragalectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28140MetatarsectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28150Phalangectomy, toe, each toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28153Resection, condyle(s), distal end of phalanx, each toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28160Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28171Radical resection of tumor; tarsal (except talus or calcaneus)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28173Radical resection of tumor; metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28175Radical resection of tumor; phalanx of toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28190Removal of foreign body, foot; subcutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28192Removal of foreign body, foot; deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28193Removal of foreign body, foot; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28200Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28202Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28208Repair, tendon, extensor, foot; primary or secondary, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28210Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28220Tenolysis, flexor, foot; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28222Tenolysis, flexor, foot; multiple tendonsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28225Tenolysis, extensor, foot; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28226Tenolysis, extensor, foot; multiple tendonsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28230Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28232Tenotomy, open, tendon flexor; toe, single tendon (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28234Tenotomy, open, extensor, foot or toe, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28238Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28240Tenotomy, lengthening, or release, abductor hallucis muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28250Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28260Capsulotomy, midfoot; medial release only (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28261Capsulotomy, midfoot; with tendon lengtheningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28262Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28264Capsulotomy, midtarsal (eg, Heyman type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28270Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28272Capsulotomy; interphalangeal joint, each joint (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28280Syndactylization, toes (eg, webbing or Kelikian type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28285Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28286Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28288Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28289Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28291Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28292Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28295Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28296Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28297Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28298Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28299Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any methodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28300Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28302Osteotomy; talusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28304Osteotomy, tarsal bones, other than calcaneus or talus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28305Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28306Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28307Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28308Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28309Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson type cavus foot procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28310Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28312Osteotomy, shortening, angular or rotational correction; other phalanges, any toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28313Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28315Sesamoidectomy, first toe (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28320Repair, nonunion or malunion; tarsal bonesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28322Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28340Reconstruction, toe, macrodactyly; soft tissue resectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28341Reconstruction, toe, macrodactyly; requiring bone resectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28344Reconstruction, toe(s); polydactylySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28345Reconstruction, toe(s); syndactyly, with or without skin graft(s), each webSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28360Reconstruction, cleft footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28400Closed treatment of calcaneal fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28405Closed treatment of calcaneal fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28406Percutaneous skeletal fixation of calcaneal fracture, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28415Open treatment of calcaneal fracture, includes internal fixation, when performed;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28420Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28430Closed treatment of talus fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28435Closed treatment of talus fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28436Percutaneous skeletal fixation of talus fracture, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28445Open treatment of talus fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28446Open osteochondral autograft, talus (includes obtaining graft[s])See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28450Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28455Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28456Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28465Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28470Closed treatment of metatarsal fracture; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28475Closed treatment of metatarsal fracture; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28476Percutaneous skeletal fixation of metatarsal fracture, with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28485Open treatment of metatarsal fracture, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28490Closed treatment of fracture great toe, phalanx or phalanges; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28495Closed treatment of fracture great toe, phalanx or phalanges; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28496Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28505Open treatment of fracture, great toe, phalanx or phalanges, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28510Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28515Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28525Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28530Closed treatment of sesamoid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28531Open treatment of sesamoid fracture, with or without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28540Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28545Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28546Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28555Open treatment of tarsal bone dislocation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28570Closed treatment of talotarsal joint dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28575Closed treatment of talotarsal joint dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28576Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28585Open treatment of talotarsal joint dislocation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28600Closed treatment of tarsometatarsal joint dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28605Closed treatment of tarsometatarsal joint dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28606Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28615Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28630Closed treatment of metatarsophalangeal joint dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28635Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28636Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28645Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28660Closed treatment of interphalangeal joint dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28665Closed treatment of interphalangeal joint dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28666Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28675Open treatment of interphalangeal joint dislocation, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28705Arthrodesis; pantalarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28715Arthrodesis; tripleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28725Arthrodesis; subtalarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28730Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28735Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28737Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (eg, Miller type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28740Arthrodesis, midtarsal or tarsometatarsal, single jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28750Arthrodesis, great toe; metatarsophalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28755Arthrodesis, great toe; interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28760Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28800Amputation, foot; midtarsal (eg, Chopart type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28805Amputation, foot; transmetatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28810Amputation, metatarsal, with toe, singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28820Amputation, toe; metatarsophalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28825Amputation, toe; interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28890Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fasciaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
28899Unlisted procedure, foot or toesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29000Application of halo type body cast (see 20661-20663 for insertion)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29010Application of Risser jacket, localizer, body; onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29015Application of Risser jacket, localizer, body; including headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29035Application of body cast, shoulder to hips;See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29040Application of body cast, shoulder to hips; including head, Minerva typeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29044Application of body cast, shoulder to hips; including 1 thighSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29046Application of body cast, shoulder to hips; including both thighsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29049Application, cast; figure-of-eightSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29055Application, cast; shoulder spicaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29058Application, cast; plaster VelpeauSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29065Application, cast; shoulder to hand (long arm)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29075Application, cast; elbow to finger (short arm)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29085Application, cast; hand and lower forearm (gauntlet)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29086Application, cast; finger (eg, contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29105Application of long arm splint (shoulder to hand)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29125Application of short arm splint (forearm to hand); staticSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29126Application of short arm splint (forearm to hand); dynamicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29130Application of finger splint; staticSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29131Application of finger splint; dynamicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29200Strapping; thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29240Strapping; shoulder (eg, Velpeau)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29260Strapping; elbow or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29280Strapping; hand or fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29305Application of hip spica cast; 1 legSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29325Application of hip spica cast; 1 and one-half spica or both legsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29345Application of long leg cast (thigh to toes);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29355Application of long leg cast (thigh to toes); walker or ambulatory typeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29358Application of long leg cast braceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29365Application of cylinder cast (thigh to ankle)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29405Application of short leg cast (below knee to toes);See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29425Application of short leg cast (below knee to toes); walking or ambulatory typeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29435Application of patellar tendon bearing (PTB) castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29440Adding walker to previously applied castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29445Application of rigid total contact leg castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29450Application of clubfoot cast with molding or manipulation, long or short legSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29505Application of long leg splint (thigh to ankle or toes)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29515Application of short leg splint (calf to foot)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29520Strapping; hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29530Strapping; kneeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29540Strapping; ankle and/or footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29550Strapping; toesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29580Strapping; Unna bootSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29581Application of multi-layer compression system; leg (below knee), including ankle and footSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29584Application of multi-layer compression system; upper arm, forearm, hand, and fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29700Removal or bivalving; gauntlet, boot or body castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29705Removal or bivalving; full arm or full leg castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29710Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc.See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29720Repair of spica, body cast or jacketSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29730Windowing of castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29740Wedging of cast (except clubfoot casts)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29750Wedging of clubfoot castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29799Unlisted procedure, casting or strappingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form
29800Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)See CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
29804Arthroscopy, temporomandibular joint, surgicalSee CommentSee CommentNon-Covered BenefitAuthorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network ProviderOutpatient Surgery e-form
Out of Network e-form
29805Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization required.
Out of Network:Authorization is required.
Out of Network e-form