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

 

Durable Medical Equipment (DME) Authorization Information

DME Authorizations

Neighborhood has partnered with Integra Partners- manages the DME vendor network and authorization process 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 LinkINTERNAL USE ONLY- Authorization TypeINTERNAL USE ONLY - Referral Category
940Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specifiedNoNo YesOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
942Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, and open urethral proceduresNoNo YesOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
944Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomyNoNo YesOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
950Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); culdoscopyNoNo YesOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
952Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingographyNoNo YesOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10005Fine needle aspiration biopsy, including ultrasound guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10007Fine needle aspiration biopsy, including fluoroscopic guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10009Fine needle aspiration biopsy, including CT guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10011Fine needle aspiration biopsy, including MR guidance; first lesionSee CommentSee CommentNon-covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10021Fine needle aspiration biopsy, without imaging guidance; first lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10040Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10080Incision and drainage of pilonidal cyst; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10081Incision and drainage of pilonidal cyst; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10120Incision and removal of foreign body, subcutaneous tissues; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10121Incision and removal of foreign body, subcutaneous tissues; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10140Incision and drainage of hematoma, seroma or fluid collectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10160Puncture aspiration of abscess, hematoma, bulla, or cystSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
10180Incision and drainage, complex, postoperative wound infectionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11000Debridement of extensive eczematous or infected skin; up to 10% of body surfaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11004Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11042Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11055Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11056Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11057Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11102Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11104Punch biopsy of skin (including simple closure, when performed); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11106Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11200Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesionsYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11201Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11300Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11301Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11302Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11303Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11305Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or lessYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11308Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cmYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11450Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11451Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11462Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11463Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11470Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11471Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repairSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11600Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11601Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11602Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11603Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11604Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11606Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11620Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11626Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11646Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11730Avulsion of nail plate, partial or complete, simple; singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11740Evacuation of subungual hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11755Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11760Repair of nail bedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11762Reconstruction of nail bed with graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11765Wedge excision of skin of nail fold (eg, for ingrown toenail)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11770Excision of pilonidal cyst or sinus; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11771Excision of pilonidal cyst or sinus; extensiveSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11772Excision of pilonidal cyst or sinus; complicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11900Injection, intralesional; up to and including 7 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11901Injection, intralesional; more than 7 lesionsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11950Subcutaneous injection of filling material (eg, collagen); 1 cc or lessYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11951Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11952Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11954Subcutaneous injection of filling material (eg, collagen); over 10.0 ccYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11960Insertion of tissue expander(s) for other than breast, including subsequent expansionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11970Replacement of tissue expander with permanent prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11971Removal of tissue expander(s) without insertion of prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
11976Removal, implantable contraceptive capsulesSee CommentSee CommentSee CommentIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
11980Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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.
Outpatient Surgery e-form
Out of Network e-form
Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
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
Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
11983Removal with reinsertion, 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
Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
12041Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
12047Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13100Repair, complex, trunk; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
13101Repair, complex, trunk; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
13120Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
13121Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14301Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
14350Filleted finger or toe flap, including preparation of recipient siteSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15040Harvest of skin for tissue cultured skin autograft, 100 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15150Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15200Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or lessSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15570Formation of direct or tubed pedicle, with or without transfer; trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15572Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15576Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15600Delay of flap or sectioning of flap (division and inset); at trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15610Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15630Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lipsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15650Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any locationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15730Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15731Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15734Muscle, myocutaneous, or fasciocutaneous flap; trunkSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15736Muscle, myocutaneous, or fasciocutaneous flap; upper extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15738Muscle, myocutaneous, or fasciocutaneous flap; lower extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15740Flap; island pedicle requiring identification and dissection of an anatomically named axial vesselSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15750Flap; neurovascular pedicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15756Free muscle or myocutaneous flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15757Free skin flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15758Free fascial flap with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15760Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15770Graft; derma-fat-fasciaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15780Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15781Dermabrasion; segmental, faceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15782Dermabrasion; regional, other than faceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15783Dermabrasion; superficial, any site (eg, tattoo removal)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15786Abrasion; single lesion (eg, keratosis, scar)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15787Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15788Chemical peel, facial; epidermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15789Chemical peel, facial; dermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15792Chemical peel, nonfacial; epidermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15793Chemical peel, nonfacial; dermalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15819CervicoplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15820Blepharoplasty, lower eyelidYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15821Blepharoplasty, lower eyelid; with extensive herniated fat padYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15822Blepharoplasty, upper eyelid;YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15823Blepharoplasty, upper eyelid; with excessive skin weighting down lidYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15830Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomyYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15840Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
15841Graft for facial nerve paralysis; free muscle graft (including obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15842Graft for facial nerve paralysis; free muscle flap by microsurgical techniqueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15845Graft for facial nerve paralysis; regional muscle transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15850Removal of sutures under anesthesia (other than local), same surgeonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15851Removal of sutures under anesthesia (other than local), other surgeonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15852Dressing change (for other than burns) under anesthesia (other than local)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15860Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15920Excision, coccygeal pressure ulcer, with coccygectomy; with primary sutureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15922Excision, coccygeal pressure ulcer, with coccygectomy; with flap closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15931Excision, sacral pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15933Excision, sacral pressure ulcer, with primary suture; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15934Excision, sacral pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15935Excision, sacral pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15936Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15937Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15940Excision, ischial pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15941Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15944Excision, ischial pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15945Excision, ischial pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15946Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15950Excision, trochanteric pressure ulcer, with primary suture;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15951Excision, trochanteric pressure ulcer, with primary suture; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15952Excision, trochanteric pressure ulcer, with skin flap closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15953Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15956Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15958Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
15999Unlisted procedure, excision pressure ulcerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
16000Initial treatment, first degree burn, when no more than local treatment is requiredSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
16035Escharotomy; initial incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
16036Escharotomy; each additional incision (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17000Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17106Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17107Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17108Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17250Chemical cauterization of granulation tissue (ie, proud flesh)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
17360Chemical exfoliation for acne (eg, acne paste, acid)YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
19000Puncture aspiration of cyst of breast;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19020Mastotomy with exploration or drainage of abscess, deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19030Injection procedure only for mammary ductogram or galactogramSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19100Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19101Biopsy of breast; open, incisionalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19105Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19110Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous ductSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19112Excision of lactiferous duct fistulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19125Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
19300Mastectomy for gynecomastiaSee CommentSee CommentNon-covered BenefitMust have diagnosis N62Outpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
19301Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19302Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomyYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19303Mastectomy, simple, completeYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19305Mastectomy, radical, including pectoral muscles, axillary lymph nodesYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19306Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19307Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscleYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19316MastopexyYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19318Breast reductionYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19325Breast augmentation with implantYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19328Removal of intact breast implantYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19330Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19340Insertion of breast implant on same day of mastectomy (ie, immediate)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19342Insertion or replacement of breast implant on separate day from mastectomyYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19350Nipple/areola reconstructionYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19355Correction of inverted nipplesYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19357Tissue expander placement in breast reconstruction, including subsequent expansion(s)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19361Breast reconstruction; with latissimus dorsi flapYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19364Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19367Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flapYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19368Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)YesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19369Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flapYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19370Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomyYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19371Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contentsYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
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 Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19396Preparation of moulage for custom breast implantYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
19499Unlisted procedure, breastYesYesNon-covered BenefitBreast Reduction e-form Other Hospital Outpatient Referral- Breast Reduction (Outpatient) Female
20100Exploration of penetrating wound (separate procedure); neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20101Exploration of penetrating wound (separate procedure); chestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20102Exploration of penetrating wound (separate procedure); abdomen/flank/backSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20103Exploration of penetrating wound (separate procedure); extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20150Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20526Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20527Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20550Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20551Injection(s); single tendon origin/insertionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20552Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20553Injection(s); single or multiple trigger point(s), 3 or more musclesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20561Needle insertion(s) without injection(s); 3 or more musclesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20600Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidanceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20612Aspiration and/or injection of ganglion cyst(s) any locationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20615Aspiration and injection for treatment of bone cystSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20660Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20661Application of halo, including removal; cranialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20662Application of halo, including removal; pelvicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20663Application of halo, including removal; femoralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20665Removal of tongs or halo applied by another individualSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20690Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20694Removal, under anesthesia, of external fixation systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20703Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20802Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20805Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20808Replantation, hand (includes hand through metacarpophalangeal joints), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20816Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20822Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20824Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20827Replantation, thumb (includes distal tip to MP joint), complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20838Replantation, foot, complete amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20912Cartilage graft; nasal septumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20920Fascia lata graft; by stripperSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20922Fascia lata graft; by incision and area exposure, complex or sheetSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20924Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20931Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20955Bone graft with microvascular anastomosis; fibulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20956Bone graft with microvascular anastomosis; iliac crestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20957Bone graft with microvascular anastomosis; metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20962Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20969Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20970Free osteocutaneous flap with microvascular anastomosis; iliac crestSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20972Free osteocutaneous flap with microvascular anastomosis; metatarsalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20973Free osteocutaneous flap with microvascular anastomosis; great toe with web spaceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20974Electrical stimulation to aid bone healing; noninvasive (nonoperative)YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
20975Electrical stimulation to aid bone healing; invasive (operative)YesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
20979Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
20999Unlisted procedure, musculoskeletal system, generalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21010Arthrotomy, temporomandibular jointYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21011Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21012Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21013Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21014Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21016Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21025Excision of bone (eg, for osteomyelitis or bone abscess); mandibleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21026Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21070Coronoidectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21076Impression and custom preparation; surgical obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21077Impression and custom preparation; orbital prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21078Impression and custom preparation; interim obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21079Impression and custom preparation; definitive obturator prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21080Impression and custom preparation; mandibular resection prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21081Impression and custom preparation; palatal augmentation prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21082Impression and custom preparation; palatal lift prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21083Impression and custom preparation; speech aid prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21084Impression and custom preparation; oral surgical splintYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21085Impression and custom preparation; oral surgical splintSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21086Impression and custom preparation; auricular prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21087Impression and custom preparation; nasal prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21088Impression and custom preparation; facial prosthesisYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21089Unlisted maxillofacial prosthetic procedureYesYesNon-Covered BenefitOutpatient Surgery e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
21100Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21110Application of interdental fixation device for conditions other than fracture or dislocation, includes removalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21116Injection procedure for temporomandibular joint arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21179Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21199Osteotomy, mandible, segmental; with genioglossus advancementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21230Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21235Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21244Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21245Reconstruction of mandible or maxilla, subperiosteal implant; partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21246Reconstruction of mandible or maxilla, subperiosteal implant; completeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21247Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21248Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21249Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); completeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21256Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21260Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21280Medial canthopexy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21282Lateral canthopexySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21295Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21296Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21325Open treatment of nasal fracture; uncomplicatedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21343Open treatment of depressed frontal sinus fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21385Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21386Open treatment of orbital floor blowout fracture; periorbital approachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21390Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21395Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21400Closed treatment of fracture of orbit, except blowout; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21401Closed treatment of fracture of orbit, except blowout; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21406Open treatment of fracture of orbit, except blowout; without implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21407Open treatment of fracture of orbit, except blowout; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21408Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21497Interdental wiring, for condition other than fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 ProviderOut of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21501Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21502Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21510Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21550Biopsy, soft tissue of neck or thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21552Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21554Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21555Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21556Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21557Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21558Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21600Excision of rib, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21601Excision of chest wall tumor including rib(s)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21602Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21603Excision of chest wall tumor involving rib(s), with plastic reconstruction; with mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21610Costotransversectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21615Excision first and/or cervical rib;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21616Excision first and/or cervical rib; with sympathectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21620Ostectomy of sternum, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21627Sternal debridementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21630Radical resection of sternum;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21632Radical resection of sternum; with mediastinal lymphadenectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21685Hyoid myotomy and suspensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21700Division of scalenus anticus; without resection of cervical ribSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21705Division of scalenus anticus; with resection of cervical ribSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21720Division of sternocleidomastoid for torticollis, open operation; without cast applicationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21725Division of sternocleidomastoid for torticollis, open operation; with cast applicationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21740Reconstructive repair of pectus excavatum or carinatum; openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21742Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21743Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21750Closure of median sternotomy separation with or without debridement (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21820Closed treatment of sternum fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21825Open treatment of sternum fracture with or without skeletal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21899Unlisted procedure, neck or thoraxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21920Biopsy, soft tissue of back or flank; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21925Biopsy, soft tissue of back or flank; deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21930Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21931Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21932Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21933Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21935Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
21936Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22010Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22015Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacralSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22210Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22212Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22214Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22220Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22222Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22224Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22310Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracingSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22505Manipulation of spine requiring anesthesia, any regionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
22526Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single levelSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
22532Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22533Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22554Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22556Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22558Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22590Arthrodesis, posterior technique, craniocervical (occiput-C2)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22595Arthrodesis, posterior technique, atlas-axis (C1-C2)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segmentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22610Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22612Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
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-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures (Other)
22800Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22802Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22804Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22808Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22810Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22812Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22830Exploration of spinal fusionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22845Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22846Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22847Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22849Reinsertion of spinal fixation deviceSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22850Removal of posterior nonsegmental instrumentation (eg, Harrington rod)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22852Removal of posterior segmental instrumentationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22855Removal of anterior instrumentationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22861Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22862Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22864Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervicalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22865Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbarSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22899Unlisted procedure, spineSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22900Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22901Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22902Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22903Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22904Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22905Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
22999Unlisted procedure, abdomen, musculoskeletal systemSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23000Removal of subdeltoid calcareous deposits, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23020Capsular contracture release (eg, Sever type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23030Incision and drainage, shoulder area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23031Incision and drainage, shoulder area; infected bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23035Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder areaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23040Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23044Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23065Biopsy, soft tissue of shoulder area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23066Biopsy, soft tissue of shoulder area; deepSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23071Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23073Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23075Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23076Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23077Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23078Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23100Arthrotomy, glenohumeral joint, including biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23101Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23105Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23106Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23107Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23120Claviculectomy; partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23125Claviculectomy; totalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23130Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament releaseSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23140Excision or curettage of bone cyst or benign tumor of clavicle or scapula;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23146Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23150Excision or curettage of bone cyst or benign tumor of proximal humerus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23156Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23170Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23172Sequestrectomy (eg, for osteomyelitis or bone abscess), scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23174Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23180Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23182Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23184Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23190Ostectomy of scapula, partial (eg, superior medial angle)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23195Resection, humeral headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23200Radical resection of tumor; clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23210Radical resection of tumor; scapulaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23220Radical resection of tumor, proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23330Removal of foreign body, shoulder; subcutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23333Removal of foreign body, shoulder; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23334Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23335Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23350Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23395Muscle transfer, any type, shoulder or upper arm; singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23397Muscle transfer, any type, shoulder or upper arm; multipleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23400Scapulopexy (eg, Sprengels deformity or for paralysis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23405Tenotomy, shoulder area; single tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23406Tenotomy, shoulder area; multiple tendons through same incisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23410Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acuteSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23412Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23415Coracoacromial ligament release, with or without acromioplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23420Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23430Tenodesis of long tendon of bicepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23440Resection or transplantation of long tendon of bicepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23450Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23455Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23460Capsulorrhaphy, anterior, any type; with bone blockSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23462Capsulorrhaphy, anterior, any type; with coracoid process transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23465Capsulorrhaphy, glenohumeral joint, posterior, with or without bone blockSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23466Capsulorrhaphy, glenohumeral joint, any type multi-directional instabilitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23470Arthroplasty, glenohumeral joint; hemiarthroplastySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23472Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23473Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23474Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23480Osteotomy, clavicle, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23490Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23491Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23500Closed treatment of clavicular fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23505Closed treatment of clavicular fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23515Open treatment of clavicular fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23520Closed treatment of sternoclavicular dislocation; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23525Closed treatment of sternoclavicular dislocation; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23530Open treatment of sternoclavicular dislocation, acute or chronic;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23532Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23540Closed treatment of acromioclavicular dislocation; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23545Closed treatment of acromioclavicular dislocation; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23550Open treatment of acromioclavicular dislocation, acute or chronic;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23552Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23570Closed treatment of scapular fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23585Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23600Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23605Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23620Closed treatment of greater humeral tuberosity fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23625Closed treatment of greater humeral tuberosity fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23630Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23650Closed treatment of shoulder dislocation, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23655Closed treatment of shoulder dislocation, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23660Open treatment of acute shoulder dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23665Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23670Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23675Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23680Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23700Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23800Arthrodesis, glenohumeral joint;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23802Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23900Interthoracoscapular amputation (forequarter)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23920Disarticulation of shoulder;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23921Disarticulation of shoulder; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23929Unlisted procedure, shoulderSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23930Incision and drainage, upper arm or elbow area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23931Incision and drainage, upper arm or elbow area; bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
23935Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24000Arthrotomy, elbow, including exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24006Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24065Biopsy, soft tissue of upper arm or elbow area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24066Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24071Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24073Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24075Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24076Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24100Arthrotomy, elbow; with synovial biopsy onlySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24102Arthrotomy, elbow; with synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24105Excision, olecranon bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24110Excision or curettage of bone cyst or benign tumor, humerus;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24115Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24116Excision or curettage of bone cyst or benign tumor, humerus; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24130Excision, radial headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24134Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24136Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24138Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon processSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24140Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24145Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24147Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon processSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24149Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24150Radical resection of tumor, shaft or distal humerusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24152Radical resection of tumor, radial head or neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24155Resection of elbow joint (arthrectomy)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24160Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar componentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24164Removal of prosthesis, includes debridement and synovectomy when performed; radial headSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24200Removal of foreign body, upper arm or elbow area; subcutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24201Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24220Injection procedure for elbow arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24300Manipulation, elbow, under anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24301Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24305Tendon lengthening, upper arm or elbow, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24310Tenotomy, open, elbow to shoulder, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24330Flexor-plasty, elbow (eg, Steindler type advancement);See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24331Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24332Tenolysis, tricepsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24340Tenodesis of biceps tendon at elbow (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24342Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24343Repair lateral collateral ligament, elbow, with local tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24344Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24345Repair medial collateral ligament, elbow, with local tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24346Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24357Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24360Arthroplasty, elbow; with membrane (eg, fascial)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24361Arthroplasty, elbow; with distal humeral prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24362Arthroplasty, elbow; with implant and fascia lata ligament reconstructionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24363Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24365Arthroplasty, radial head;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24366Arthroplasty, radial head; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24370Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24371Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar componentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24400Osteotomy, humerus, with or without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24410Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24420Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24430Repair of nonunion or malunion, humerus; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24435Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24470Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24495Decompression fasciotomy, forearm, with brachial artery explorationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24498Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24500Closed treatment of humeral shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24505Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24515Open treatment of humeral shaft fracture with plate/screws, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24530Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24538Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24545Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24546Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extensionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24560Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24565Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24566Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24575Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24576Closed treatment of humeral condylar fracture, medial or lateral; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24577Closed treatment of humeral condylar fracture, medial or lateral; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24579Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24582Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24600Treatment of closed elbow dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24605Treatment of closed elbow dislocation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24615Open treatment of acute or chronic elbow dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24640Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24650Closed treatment of radial head or neck fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24655Closed treatment of radial head or neck fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24670Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24675Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24800Arthrodesis, elbow joint; localSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24802Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24900Amputation, arm through humerus; with primary closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24920Amputation, arm through humerus; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24925Amputation, arm through humerus; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24930Amputation, arm through humerus; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24931Amputation, arm through humerus; with implantSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24935Stump elongation, upper extremitySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24940Cineplasty, upper extremity, complete procedureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
24999Unlisted procedure, humerus or elbowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25000Incision, extensor tendon sheath, wrist (eg, deQuervains disease)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25001Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25028Incision and drainage, forearm and/or wrist; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25031Incision and drainage, forearm and/or wrist; bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25035Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25040Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25065Biopsy, soft tissue of forearm and/or wrist; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25066Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25071Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25073Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25075Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25076Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25085Capsulotomy, wrist (eg, contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25100Arthrotomy, wrist joint; with biopsySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25105Arthrotomy, wrist joint; with synovectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25107Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complexSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25109Excision of tendon, forearm and/or wrist, flexor or extensor, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25110Excision, lesion of tendon sheath, forearm and/or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25111Excision of ganglion, wrist (dorsal or volar); primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25112Excision of ganglion, wrist (dorsal or volar); recurrentSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25118Synovectomy, extensor tendon sheath, wrist, single compartment;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25119Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25130Excision or curettage of bone cyst or benign tumor of carpal bones;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25136Excision or curettage of bone cyst or benign tumor of carpal bones; with allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25145Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25150Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25151Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25170Radical resection of tumor, radius or ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25210Carpectomy; 1 boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25215Carpectomy; all bones of proximal rowSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25230Radial styloidectomy (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25240Excision distal ulna partial or complete (eg, Darrach type or matched resection)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25246Injection procedure for wrist arthrographySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25248Exploration with removal of deep foreign body, forearm or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25250Removal of wrist prosthesis; (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25251Removal of wrist prosthesis; complicated, including total wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25259Manipulation, wrist, under anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25260Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25263Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25270Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25272Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25280Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25290Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25295Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25300Tenodesis at wrist; flexors of fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25301Tenodesis at wrist; extensors of fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25310Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25315Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25316Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25332Arthroplasty, wrist, with or without interposition, with or without external or internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25335Centralization of wrist on ulna (eg, radial club hand)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25350Osteotomy, radius; distal thirdSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25355Osteotomy, radius; middle or proximal thirdSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25360Osteotomy; ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25365Osteotomy; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25370Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25375Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25390Osteoplasty, radius OR ulna; shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25391Osteoplasty, radius OR ulna; lengthening with autograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25392Osteoplasty, radius AND ulna; shortening (excluding 64876)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25393Osteoplasty, radius AND ulna; lengthening with autograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25394Osteoplasty, carpal bone, shorteningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25400Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25405Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25415Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25420Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25425Repair of defect with autograft; radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25426Repair of defect with autograft; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25430Insertion of vascular pedicle into carpal bone (eg, Hori procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25441Arthroplasty with prosthetic replacement; distal radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25442Arthroplasty with prosthetic replacement; distal ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25443Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25444Arthroplasty with prosthetic replacement; lunateSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25445Arthroplasty with prosthetic replacement; trapeziumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25446Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25447Arthroplasty, interposition, intercarpal or carpometacarpal jointsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25449Revision of arthroplasty, including removal of implant, wrist jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25450Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25455Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25490Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radiusSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25491Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25492Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25500Closed treatment of radial shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25505Closed treatment of radial shaft fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25515Open treatment of radial shaft fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25530Closed treatment of ulnar shaft fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25535Closed treatment of ulnar shaft fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25545Open treatment of ulnar shaft fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25560Closed treatment of radial and ulnar shaft fractures; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25565Closed treatment of radial and ulnar shaft fractures; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25574Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25575Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulnaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25606Percutaneous skeletal fixation of distal radial fracture or epiphyseal separationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25607Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25608Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragmentsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25622Closed treatment of carpal scaphoid (navicular) fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25624Closed treatment of carpal scaphoid (navicular) fracture; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25628Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25630Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25635Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25645Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25650Closed treatment of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25651Percutaneous skeletal fixation of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25652Open treatment of ulnar styloid fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25660Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25670Open treatment of radiocarpal or intercarpal dislocation, 1 or more bonesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25671Percutaneous skeletal fixation of distal radioulnar dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25675Closed treatment of distal radioulnar dislocation with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25676Open treatment of distal radioulnar dislocation, acute or chronicSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25680Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25685Open treatment of trans-scaphoperilunar type of fracture dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25690Closed treatment of lunate dislocation, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25695Open treatment of lunate dislocationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25800Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25805Arthrodesis, wrist; with sliding graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25810Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25820Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25825Arthrodesis, wrist; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25900Amputation, forearm, through radius and ulna;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25905Amputation, forearm, through radius and ulna; open, circular (guillotine)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25907Amputation, forearm, through radius and ulna; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25909Amputation, forearm, through radius and ulna; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25915Krukenberg procedureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25920Disarticulation through wrist;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25922Disarticulation through wrist; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25924Disarticulation through wrist; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25927Transmetacarpal amputation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25929Transmetacarpal amputation; secondary closure or scar revisionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25931Transmetacarpal amputation; re-amputationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
25999Unlisted procedure, forearm or wristSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26010Drainage of finger abscess; simpleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26011Drainage of finger abscess; complicated (eg, felon)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26020Drainage of tendon sheath, digit and/or palm, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26025Drainage of palmar bursa; single, bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26030Drainage of palmar bursa; multiple bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26034Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26035Decompression fingers and/or hand, injection injury (eg, grease gun)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26037Decompressive fasciotomy, hand (excludes 26035)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26040Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneousSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26045Fasciotomy, palmar (eg, Dupuytren's contracture); open, partialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26055Tendon sheath incision (eg, for trigger finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26060Tenotomy, percutaneous, single, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26070Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26075Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26080Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26100Arthrotomy with biopsy; carpometacarpal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26105Arthrotomy with biopsy; metacarpophalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26110Arthrotomy with biopsy; interphalangeal joint, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26111Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26115Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26117Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26118Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26130Synovectomy, carpometacarpal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26135Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26140Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26145Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26170Excision of tendon, palm, flexor or extensor, single, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26180Excision of tendon, finger, flexor or extensor, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26185Sesamoidectomy, thumb or finger (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26200Excision or curettage of bone cyst or benign tumor of metacarpal;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26205Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26230Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26235Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26236Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26250Radical resection of tumor, metacarpalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26260Radical resection of tumor, proximal or middle phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26262Radical resection of tumor, distal phalanx of fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26320Removal of implant from finger or handSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26340Manipulation, finger joint, under anesthesia, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26341Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cordSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26370Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26373Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26390Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rodSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26410Repair, extensor tendon, hand, primary or secondary; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26412Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26418Repair, extensor tendon, finger, primary or secondary; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26420Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26432Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26433Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26434Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26437Realignment of extensor tendon, hand, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26440Tenolysis, flexor tendon; palm OR finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26442Tenolysis, flexor tendon; palm AND finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26445Tenolysis, extensor tendon, hand OR finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26449Tenolysis, complex, extensor tendon, finger, including forearm, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26450Tenotomy, flexor, palm, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26455Tenotomy, flexor, finger, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26460Tenotomy, extensor, hand or finger, open, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26471Tenodesis; of proximal interphalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26474Tenodesis; of distal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26476Lengthening of tendon, extensor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26477Shortening of tendon, extensor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26478Lengthening of tendon, flexor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26479Shortening of tendon, flexor, hand or finger, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26480Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26485Transfer or transplant of tendon, palmar; without free tendon graft, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26489Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26490Opponensplasty; superficialis tendon transfer type, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26492Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26494Opponensplasty; hypothenar muscle transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26496Opponensplasty; other methodsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26497Transfer of tendon to restore intrinsic function; ring and small fingerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26498Transfer of tendon to restore intrinsic function; all 4 fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26499Correction claw finger, other methodsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26500Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26502Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26508Release of thenar muscle(s) (eg, thumb contracture)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26510Cross intrinsic transfer, each tendonSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26516Capsulodesis, metacarpophalangeal joint; single digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26517Capsulodesis, metacarpophalangeal joint; 2 digitsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26518Capsulodesis, metacarpophalangeal joint; 3 or 4 digitsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26520Capsulectomy or capsulotomy; metacarpophalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26525Capsulectomy or capsulotomy; interphalangeal joint, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26530Arthroplasty, metacarpophalangeal joint; each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26531Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26535Arthroplasty, interphalangeal joint; each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26536Arthroplasty, interphalangeal joint; with prosthetic implant, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26540Repair of collateral ligament, metacarpophalangeal or interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26541Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26542Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26545Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26548Repair and reconstruction, finger, volar plate, interphalangeal jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26550Pollicization of a digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26551Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26553Transfer, toe-to-hand with microvascular anastomosis; other than great toe, singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26554Transfer, toe-to-hand with microvascular anastomosis; other than great toe, doubleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26555Transfer, finger to another position without microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26556Transfer, free toe joint, with microvascular anastomosisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26560Repair of syndactyly (web finger) each web space; with skin flapsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26561Repair of syndactyly (web finger) each web space; with skin flaps and graftsSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26562Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26565Osteotomy; metacarpal, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26567Osteotomy; phalanx of finger, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26568Osteoplasty, lengthening, metacarpal or phalanxSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26580Repair cleft handSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26587Reconstruction of polydactylous digit, soft tissue and boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26590Repair macrodactylia, each digitSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26591Repair, intrinsic muscles of hand, each muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26593Release, intrinsic muscles of hand, each muscleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26596Excision of constricting ring of finger, with multiple Z-plastiesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26600Closed treatment of metacarpal fracture, single; without manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26605Closed treatment of metacarpal fracture, single; with manipulation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26607Closed treatment of metacarpal fracture, with manipulation, with external fixation, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26608Percutaneous skeletal fixation of metacarpal fracture, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26615Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each boneSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26641Closed treatment of carpometacarpal dislocation, thumb, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26645Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26650Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26665Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26670Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26675Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26676Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26685Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26686Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reductionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26700Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26705Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26706Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26715Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26720Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26740Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26742Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26746Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26750Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26755Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26756Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26765Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, eachSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26770Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26775Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26776Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26785Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, singleSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26820Fusion in opposition, thumb, with autogenous graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26841Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26842Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26843Arthrodesis, carpometacarpal joint, digit, other than thumb, each;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26844Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26850Arthrodesis, metacarpophalangeal joint, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26852Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26860Arthrodesis, interphalangeal joint, with or without internal fixation;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26862Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26910Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transferSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26951Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26989Unlisted procedure, hands or fingersSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26990Incision and drainage, pelvis or hip joint area; deep abscess or hematomaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26991Incision and drainage, pelvis or hip joint area; infected bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
26992Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27000Tenotomy, adductor of hip, percutaneous (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27001Tenotomy, adductor of hip, openSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27003Tenotomy, adductor, subcutaneous, open, with obturator neurectomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27005Tenotomy, hip flexor(s), open (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27006Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27025Fasciotomy, hip or thigh, any typeSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27030Arthrotomy, hip, with drainage (eg, infection)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27033Arthrotomy, hip, including exploration or removal of loose or foreign bodySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27035Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nervesSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27040Biopsy, soft tissue of pelvis and hip area; superficialSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27041Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscularSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27043Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27045Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27047Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27048Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27049Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cmSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27050Arthrotomy, with biopsy; sacroiliac jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27052Arthrotomy, with biopsy; hip jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27054Arthrotomy with synovectomy, hip jointSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27059Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greaterSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27060Excision; ischial bursaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27062Excision; trochanteric bursa or calcificationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27075Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubisSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27076Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27077Radical resection of tumor; innominate bone, totalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27078Radical resection of tumor; ischial tuberosity and greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27080Coccygectomy, primarySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27086Removal of foreign body, pelvis or hip; subcutaneous tissueSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27087Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27090Removal of hip prosthesis; (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27091Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacerSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27093Injection procedure for hip arthrography; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27095Injection procedure for hip arthrography; with anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27096Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performedYesYesNon-covered BenefitPain Managament Request e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Pain Management
27097Release or recession, hamstring, proximalSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27098Transfer, adductor to ischiumSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27100Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27105Transfer paraspinal muscle to hip (includes fascial or tendon extension graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27110Transfer iliopsoas; to greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27111Transfer iliopsoas; to femoral neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27120Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27122Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27125Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27132Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27134Revision of total hip arthroplasty; both components, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27137Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27138Revision of total hip arthroplasty; femoral component only, with or without allograftSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27140Osteotomy and transfer of greater trochanter of femur (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27146Osteotomy, iliac, acetabular or innominate bone;See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27147Osteotomy, iliac, acetabular or innominate bone; with open reduction of hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27151Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomySee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27156Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hipSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27158Osteotomy, pelvis, bilateral (eg, congenital malformation)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27161Osteotomy, femoral neck (separate procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27165Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or castSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27170Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27175Treatment of slipped femoral epiphysis; by traction, without reductionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27176Treatment of slipped femoral epiphysis; by single or multiple pinning, in situSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27177Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27178Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinningSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27179Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure)See CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27181Open treatment of slipped femoral epiphysis; osteotomy and internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27185Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27187Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femurSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27200Closed treatment of coccygeal fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27202Open treatment of coccygeal fractureSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27220Closed treatment of acetabulum (hip socket) fracture(s); without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27222Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27226Open treatment of posterior or anterior acetabular wall fracture, with internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27230Closed treatment of femoral fracture, proximal end, neck; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27232Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal tractionSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27235Percutaneous skeletal fixation of femoral fracture, proximal end, neckSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27236Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacementSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27238Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27244Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclageSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27246Closed treatment of greater trochanteric fracture, without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27248Open treatment of greater trochanteric fracture, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27250Closed treatment of hip dislocation, traumatic; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27252Closed treatment of hip dislocation, traumatic; requiring anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27253Open treatment of hip dislocation, traumatic, without internal fixationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27265Closed treatment of post hip arthroplasty dislocation; without anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27266Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27267Closed treatment of femoral fracture, proximal end, head; without manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27268Closed treatment of femoral fracture, proximal end, head; with manipulationSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27269Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performedSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
27275Manipulation, hip joint, requiring general anesthesiaSee CommentSee CommentNon-Covered BenefitIn Network: No authorization is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON
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 is required
Out of Network:Authorization is required.
Out of Network e-formOutpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician ServicesReferral- Outpatient Surgery and Procedures Other OON