Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   


Policy #
Policy Bulletin Title

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00.01.14q
Reporting and Documentation Requirements for Anesthesia Services
00.01.18c
Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.19d
Facility Reporting of Observation Services
00.01.24h
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.01.25au
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
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00.01.41b
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
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00.01.44h
Never Events and Preventable Adverse Events
00.01.45
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
00.01.47c
Inpatient Hospital Readmission
00.01.48c
Marijuana for Medical Use
00.01.49c
Reporting Requirements for Drugs and Biologics
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00.01.52h
Always Bundled Procedure Codes
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00.01.55n
New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
00.01.56a
National Correct Coding Initiative (NCCI) Code Pair Edits
00.01.59e
Care Management and Care Planning Services
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00.01.60c
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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00.01.61
Reimbursement for Components of Comprehensive Laboratory Panels
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00.01.66b
Musculoskeletal Services (AmeriHealth)
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00.01.68
Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
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00.03.02y
Diagnostic Radiology Services Included in Capitation
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00.03.03g
Outpatient Short-Term Rehabilitation Services Included in Capitation
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00.03.06f
Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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00.03.07x
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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00.03.09d
X-rays Associated with Fractures in the Office Setting
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00.03.10e
Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.05.01e
Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program
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00.06.02aa
Preventive Care Services (AmeriHealth)
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00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
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00.10.01ab
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.03i
Criteria for Reimbursement of Emergency Room Services
00.10.11k
Modifier 62: Two Surgeons
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.16d
Physician/Nonphysician Standby Services
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00.10.17h
Modifier 66: Surgical Team
00.10.18j
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
00.10.31c
Medical Team Conferences
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00.10.36p
Radiologic Guidance of a Procedure
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00.10.38
Billing Requirements for Multiple Births for Professional Providers
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00.10.39j
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.40d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
00.10.41e
Telemedicine Services (Amerihealth PA)
00.10.42b
Telemedicine and Telehealth Services (Amerihealth New Jersey)
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
01.00.08c
Preoperative Consultations Performed by Providers in Anesthesia Specialties
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
02.01.01d
Home Health Care Services
02.01.02c
Private Duty Nursing
02.02.01g
Hospice Care
03.00.02a
Modifier 76: Repeat Procedure by Same Physician
03.00.05i
Modifier 50: Bilateral Procedure
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03.00.06p
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.08d
Modifiers XE, XS, XP, XU, 59
03.00.11a
Modifier 77: Repeat Procedure by Another Physician
03.00.12e
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
03.00.15n
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
03.00.16n
Modifier 57: Decision for Surgery
03.00.20i
Modifiers 26 (Professional Component) and TC (Technical Component)
03.00.28l
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
03.00.31e
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.32
Modifier 52 Reduced Services
03.00.33
Modifier 53: Discontinued Procedure
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
03.02.13f
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
03.12.04c
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
04.00.03a
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
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05.00.01l
Pneumatic Compression Therapy Devices
05.00.04e
Coverage of Medical Devices
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05.00.05k
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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05.00.11i
Therapeutic Shoes and Orthopedic Shoes
05.00.12g
Manual Wheelchairs
05.00.14j
High-Frequency Chest Wall Oscillation Devices
05.00.15p
Nebulizers and Inhalation Solutions
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05.00.21t
Durable Medical Equipment (DME) and Consumable Medical Supplies
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.25h
Cranial Remolding Orthoses (Helmets)
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05.00.26i
Home Prothrombin Time Monitoring
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.30m
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (AmeriHealth Adminstrators)
05.00.31e
Pulse Oximetry Devices in the Home Setting
05.00.32i
Speech and Non-Speech Generating Devices
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05.00.35e
Foot Orthotics and Other Podiatric Appliances
05.00.37f
Compression Garments
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.42g
Patient Lifts
05.00.43f
Seat Lift Mechanisms
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
05.00.45k
Repair or Replacement of an External Prosthetic Device
05.00.47n
Knee Orthoses
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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05.00.50k
Ostomy Supplies
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
05.00.55i
Wheelchair Cushions and Seating
05.00.56i
Hospital Beds and Accessories
05.00.58l
Home Oxygen Therapy
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05.00.59j
Lower Limb Prostheses
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05.00.60h
Pressure-Reducing Support Surfaces
05.00.61f
Cervical Traction Devices for In-home Use
05.00.62h
Injectable Dermal Fillers
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05.00.67o
Wheelchair Options and Accessories
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
05.00.71c
Standing Frames
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05.00.72f
Upper Limb Prostheses
05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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05.00.74d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
05.00.76b
Breast Pumps
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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05.00.79a
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.80
Cranial Electrotherapy Stimulation
06.02.01i
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
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06.02.06p
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (AmeriHealth Administrators)
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (AmeriHealth Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (AmeriHealth Administrators)
06.02.14h
In Vitro Chemosensitivity and Chemoresistance Assays
06.02.17f
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
06.02.18k
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (AmeriHealth Administrators)
06.02.24j
Preimplantation Genetic Testing (AmeriHealth Administrators)
06.02.26d
In Vitro Allergy Testing
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators)
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
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06.02.30e
Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (AmeriHealth Administrators)
06.02.32d
Multigene Expression Assays for Predicting Recurrence in Colon Cancer (AmeriHealth Administrators)
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06.02.35v
Genetic Testing (AmeriHealth Administrators)
06.02.36c
Molecular Testing for the Management of Pancreatic Cysts or Barrett's Esophagus (AmeriHealth Administrators)
06.02.37a
Immune Cell Function Assay
06.02.38d
Nerve Fiber Density Testing
06.02.39c
Measurement of Serum Antibodies to and Measurement of Serum Levels Using Anser™ or DoseAssure™ Tests
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
06.02.44k
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
06.02.47b
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA (AmeriHealth Administrators)
06.02.49b
VeriStrat® Testing for Targeted Therapy in Non-Small Cell Lung Cancer
06.02.50
GPS Cancer™ Testing by NantHealth
06.02.51c
Testing Serum Vitamin D Levels
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06.02.52n
eviCore Lab Management Program (AmeriHealth)
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
06.02.56a
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
06.03.04n
Apheresis Therapy
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
07.00.01h
Biofeedback Therapy
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07.00.02i
Intravenous Chelation Therapy
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.05g
In Vivo Allergy Sensitivity Testing
07.00.09d
Topical Oxygenation
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.00.14g
Low-level Laser Therapy (LLLT)
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
07.00.21i
Allergy Immunotherapy
07.02.05j
External Counterpulsation (ECP)
07.02.09f
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21d
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
07.03.05v
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)
07.03.07r
Evaluation and Management of Autism Spectrum Disorders (ASD)
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.03.14n
Intraoperative Neurophysiological Monitoring (INM)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
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07.03.18o
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.22c
Transcranial Magnetic Stimulation (TMS)
07.03.23b
Autonomic Nervous System Testing
07.03.24a
Laboratory-Based Vestibular Function Testing
07.03.25
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.03.26
Tumor Treating Fields
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.06f
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
07.05.08a
Fecal Microbiota Transplantation (FMT)
07.06.01b
Complete Decongestive Therapy (CDT)
07.06.03b
Bioimpedance for the Detection of Lymphedema
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07.07.01o
Routine Foot Care for Certain Medical Conditions
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
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07.07.07g
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
07.07.09f
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.08.03d
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
07.10.05l
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.10.06g
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
07.11.01c
Smell and Taste Dysfunction Testing
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
07.13.01h
Orthoptic/Pleoptic Training
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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07.13.07j
Corneal Pachymetry Using Ultrasound
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07.13.08e
Partial Coherence Interferometry
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.12d
Instrument-Based Vision Screening
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07.13.13c
Prescription Lenses and Visual Devices
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
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08.00.13v
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.15e
Off-label Coverage for Prescription Drugs and/or Biologics
08.00.17g
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.00.25k
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
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08.00.26u
Botulinum Toxin Agents
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08.00.33n
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
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08.00.34m
Infliximab and Related Biosimilars
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
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08.00.50t
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
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08.00.55h
Omalizumab (Xolair®)
08.00.57m
Treatments for Complex Regional Pain Syndrome (CRPS)
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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.64g
Natalizumab (Tysabri®)
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08.00.66m
Bevacizumab (Avastin®) and Related Biosimilars
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08.00.67k
Cetuximab (Erbitux®)
08.00.69b
Agalsidase beta (Fabrazyme®)
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.74l
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
08.00.75m
Erythropoiesis-Stimulating Agents (ESAs)
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08.00.78ad
Self-Administered Drugs
08.00.82j
Ustekinumab (Stelara®)
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08.00.83h
Pralatrexate (Folotyn®) for Injection
08.00.84f
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
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08.00.85h
Tocilizumab (Actemra®) for Intravenous Infusion
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08.00.87e
Pemetrexed (Alimta®)
08.00.88e
Ofatumumab (Arzerra™)
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08.00.90j
Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
08.00.92aa
Coagulation Factors
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.95d
Personalized Vaccines (e.g. Provenge®)
08.00.96d
Cabazitaxel (Jevtana®)
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08.00.97i
Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
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08.01.01h
Ipilimumab (Yervoy®)
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08.01.02d
Pegloticase (Krystexxa®)
08.01.03c
Belatacept (Nulojix®)
08.01.04u
Immunizations
08.01.05f
Carfilzomib (Kyprolis™)
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08.01.07f
Pertuzumab (Perjeta®)
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
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08.01.10d
Octreotide acetate (Sandostatin® LAR Depot)
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
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08.01.13c
Brentuximab Vedotin (Adcetris®)
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (AmeriHealth Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
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08.01.18c
Vedolizumab (Entyvio®)
08.01.19e
Siltuximab (Sylvant®)
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08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
08.01.21c
Blinatumomab (Blincyto®)
08.01.22c
Alemtuzumab (Lemtrada®)
08.01.23e
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
08.01.24
Deoxycholic Acid (Kybella™)
08.01.25c
Ramucirumab (Cyramza®)
08.01.26b
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
08.01.27d
Talimogene laherparepvec (Imlygic™)
08.01.28c
Sebelipase alfa (Kanuma®)
08.01.29d
Daratumumab (Darzalex™)
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08.01.32a
Pegfilgrastim (Neulasta®) and Related Biosimilars
08.01.33a
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
08.01.35a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
08.01.36d
Nusinersen (Spinraza®)
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
08.01.38c
Ocrelizumab (Ocrevus®)
08.01.39c
Cerliponase alfa (Brineura®)
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08.01.40a
Lanreotide (Somatuline® Depot)
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.42a
Edaravone (Radicava™)
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08.01.43d
Chimeric Antigen Receptor (CAR) Therapy
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
08.01.48a
Tildrakizumab-asmn (Ilumya™)
08.01.49a
Burosumab-twza (Crysvita®)
08.01.50b
Patisiran (Onpattro™)
08.01.51
Canakinumab (Ilaris®)
08.01.52a
Mogamulizumab-kpkc (Poteligeo®)
08.01.53b
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
08.01.54b
Emapalumab-lzsg (Gamifant®)
08.01.55b
Tagraxofusp-erzs (Elzonris™)
08.01.57
Lutathera® (Lutetium Lu 177 Dotatate) (AmeriHealth Administrators)
08.01.59
Polatuzumab Vedotin-Piiq (Polivy™)
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
09.00.04j
Bone Mineral Density (BMD) Testing
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators)
09.00.11c
Echocardiography Contrast Agents
09.00.13c
High Osmolar Contrast Agents
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (AmeriHealth Administrators)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
09.00.31d
Low Osmolar Contrast Agents
09.00.32t
Reimbursement for Diagnostic and Therapeutic Radiopharmaceutical Agents for Professional Providers
09.00.36k
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
09.00.40d
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
09.00.45g
Magnetic Resonance Imaging (MRI) Contrast Agents
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09.00.46x NJ
High-Technology Radiology Services (AmeriHealth New Jersey)
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09.00.46x PA
High-Technology Radiology Services (AmeriHealth Pennsylvania)
09.00.48f
Radioembolization for Primary and Metastatic Tumors of the Liver (AmeriHealth Administrators)
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09.00.49l
Proton Beam Radiation Therapy
09.00.51a
Positron Emission Mammography (PEM)
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09.00.56i
Radiation Therapy Services (AmeriHealth)
10.00.02b
Day Rehabilitation
10.00.03
Pediatric Intensive Day Feeding Program
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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10.02.02i
Chiropractic Spinal and Extraspinal Manipulation Therapy
10.03.01j
Physical Medicine, Rehabilitation, and Habilitation Services
10.04.01k
Pulmonary Rehabilitation
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10.06.01k
Speech Therapy
11.00.02f
Treatment of Medical and Surgical Complications
11.00.03j
Fetal Surgery
11.00.06j
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
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11.00.10u
Multiple Surgical Reduction Guidelines (AmeriHealth)
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11.00.11k
Use of an Operating Microscope During a Surgical Procedure
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
11.00.14f
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
11.00.18a
Use of a Robotic-Assisted Surgical System
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
11.01.02n
Cochlear Implant
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
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11.01.07d
Cataract Surgery
11.02.01s
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
11.02.10m
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.02.16r
Ventricular Assist Devices (VADs)
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
11.02.19f
Total Artificial Hearts (TAHs)
11.02.25f
Transcatheter Cardiac Valve Procedures
11.02.26b
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
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11.02.27b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
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11.03.02s
Bariatric Surgery
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
11.03.12r
Colorectal Cancer Screening
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
11.04.01c
Islet Cell Transplantation
11.05.01f
Refractive Keratoplasty
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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11.05.07d
Surgical Correction of Strabismus
11.05.08d
Photocoagulation of Macular Drusen
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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11.06.02i
Elective Abortion
11.06.04k
Uterine Artery Embolization
11.06.05f
Endometrial Ablation
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
11.06.09d
Labiaplasty
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11.07.01t
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
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11.07.02j
Sentinel Lymph Node Biopsy and Mapping
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11.08.01g
Hair Transplants and Cranial Prostheses (Wigs)
11.08.02h
Reduction Mammoplasty
11.08.03j
Lipectomy and Liposuction
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
11.08.05g
Application and Removal of Tattoos
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
11.08.08g
Chemical Peels
11.08.12h
Surgery for Gynecomastia
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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11.08.14j
Removal of Breast Implants
11.08.15w
Reconstructive Breast Surgery
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.19n
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
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11.08.20u
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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11.08.23j
Mohs' Micrographic Surgery
11.08.25m
Scar Revision
11.08.29e
Procedures for the Treatment of Acne
11.09.02g
Treatment of Gender Dysphoria
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
11.11.03d
Cryosurgical Ablation of the Prostate Gland
11.11.06h
Saturation Needle Biopsy of the Prostate
11.14.01g
Mentoplasty or Genioplasty
11.14.02n
Trigger Point Injections
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11.14.03f
Meniscal Allograft Transplantation
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
11.14.07t
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
11.14.08d
Orthognathic Surgery
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
11.14.10q
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
11.14.12e
Osteochondral Allograft Transplantation
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
11.14.19m
Artificial Intervertebral Disc Insertion
11.14.21g
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
11.14.22d
Spinal Decompression with Interspinous and Interlaminar Devices
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
11.14.24b
Manipulation Under Anesthesia
11.14.26a
Surgical Treatments of Athletic Pubalgia
11.14.27c
Spinal Fusion
11.14.28b
Spinal Laminectomy
11.14.29d
Spinal Discectomy
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
11.15.01v
Spinal Cord and Dorsal Root Ganglion Stimulation
11.15.03j
Insertion of Implantable Infusion Pumps
11.15.09l
Denervation of the Spinal Nerves for Chronic Pain
11.15.13d
Lysis of Epidural Adhesions
11.15.15g
Percutaneous Discectomy
11.15.16n
Vagus Nerve Stimulation (VNS)
11.15.19e
Nucleoplasty
11.15.20o
Deep Brain Stimulation (DBS)
11.15.22d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
11.15.23g
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
11.15.24a
Migraine Deactivation Surgery
11.16.01h
Septoplasty, Rhinoplasty, and Septorhinoplasty
11.16.06i
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
11.16.07b
Bronchial Thermoplasty
11.16.08c
Implantable Steroid-Eluting Sinus Stents
11.17.04s
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
11.17.06l
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
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12.00.01f
Acupuncture
12.00.03f
Complementary and Integrative Health Services
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12.01.01at
Experimental/Investigational Services
12.01.02
Medical Necessity
12.01.03
Cosmetic Procedures
12.04.02h
Ground Ambulance Transport Services (Emergency and Nonemergency)
12.04.03c
Air Ambulance Services
12.04.04
Acute Care Facility Inpatient Transfers
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12.05.01i
Outpatient Diabetes Education and Self-Management Training