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

New Century Health Portal: https://my.newcenturyhealth.com
New Century Health Fax: 877-624-8602
New Century Health Phone: 888-999-7713

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).

Integra Partners: https://accessintegra.com
Integra Partners Fax: 248-844-3824
Integra Partners Phone: (888) 729-8818

Code	Code Description	Authorization Required RIte Care (MED), CSN, and Sub Care	Authorization Required RHODY HEALTH EXPANSION (RHE) RHODY HEALTH PARTNERS (RHP)	Authorization Required Extended Family Planning (EFP)	Comments	Form Link	INTERNAL USE ONLY- Authorization Type	INTERNAL USE ONLY - Referral Category
940	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified	No	No	Yes		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
942	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, and open urethral procedures	No	No	Yes		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
944	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy	No	No	Yes		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
950	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); culdoscopy	No	No	Yes		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
952	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography	No	No	Yes		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
10004	Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10005	Fine needle aspiration biopsy, including ultrasound guidance; first lesion	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10006	Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10007	Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10008	Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10009	Fine needle aspiration biopsy, including CT guidance; first lesion	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10010	Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10011	Fine needle aspiration biopsy, including MR guidance; first lesion	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10012	Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10021	Fine needle aspiration biopsy, without imaging guidance; first lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10030	Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10035	Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10036	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10040	Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10060	Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10061	Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10080	Incision and drainage of pilonidal cyst; simple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10081	Incision and drainage of pilonidal cyst; complicated	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10120	Incision and removal of foreign body, subcutaneous tissues; simple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10121	Incision and removal of foreign body, subcutaneous tissues; complicated	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10140	Incision and drainage of hematoma, seroma or fluid collection	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10160	Puncture aspiration of abscess, hematoma, bulla, or cyst	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
10180	Incision and drainage, complex, postoperative wound infection	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11000	Debridement of extensive eczematous or infected skin; up to 10% of body surface	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11001	Debridement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11004	Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11005	Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11006	Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11008	Removal 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11010	Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11011	Debridement 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 muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11012	Debridement 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 bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11042	Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11043	Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11044	Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11045	Debridement, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11046	Debridement, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11047	Debridement, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11055	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11056	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11102	Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11103	Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11104	Punch biopsy of skin (including simple closure, when performed); single lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11105	Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11106	Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11107	Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11201	Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11300	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11301	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11302	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11303	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11305	Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11306	Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11308	Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11310	Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11311	Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11312	Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11313	Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11400	Excision, 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.)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11401	Excision, 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.)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11403	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11404	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11406	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11420	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11421	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11422	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11423	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11424	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11426	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- 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 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11446	Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11450	Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11451	Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11462	Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11463	Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11470	Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11471	Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11600	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11601	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11602	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11603	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11604	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11606	Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11620	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11621	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11622	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11623	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11624	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11626	Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11640	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
11641	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
11642	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
11643	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11644	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11646	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11730	Avulsion of nail plate, partial or complete, simple; single	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11732	Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11740	Evacuation of subungual hematoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11750	Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11755	Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11760	Repair of nail bed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11762	Reconstruction of nail bed with graft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11765	Wedge excision of skin of nail fold (eg, for ingrown toenail)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11770	Excision of pilonidal cyst or sinus; simple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11771	Excision of pilonidal cyst or sinus; extensive	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11772	Excision of pilonidal cyst or sinus; complicated	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11900	Injection, intralesional; up to and including 7 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11901	Injection, intralesional; more than 7 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11922	Tattooing, 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)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11970	Replacement of tissue expander with permanent prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11971	Removal of tissue expander(s) without insertion of prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
11976	Removal, implantable contraceptive capsules	See Comment	See Comment	See Comment	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
11981	Insertion, non-biodegradable drug delivery implant	See Comment	See Comment	See Comment	In 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 Services	Referral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
11982	Removal, non-biodegradable drug delivery implant	See Comment	See Comment	See Comment	In 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 Services	Referral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
11983	Removal with reinsertion, non-biodegradable drug delivery implant	See Comment	See Comment	See Comment	In 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 Services	Referral- Surgical Services EFP or Referral- Outpatient Surgery and Procedures Other OON
12001	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12002	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12004	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12005	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12006	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12007	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12011	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12013	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12014	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12015	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12016	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12017	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12018	Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12020	Treatment of superficial wound dehiscence; simple closure	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12021	Treatment of superficial wound dehiscence; with packing	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12031	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12032	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12034	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12035	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12036	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12037	Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12041	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12042	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12044	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12045	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12046	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12047	Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
12051	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12052	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12053	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12054	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12055	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12056	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
12057	Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13100	Repair, complex, trunk; 1.1 cm to 2.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13101	Repair, complex, trunk; 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13102	Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13120	Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13121	Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13122	Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
13131	Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13132	Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13133	Repair, 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13150	Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13151	Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13152	Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13153	Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
13160	Secondary closure of surgical wound or dehiscence, extensive or complicated	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14020	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14021	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14060	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14061	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14300	Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
14301	Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
14302	Adjacent 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
14350	Filleted finger or toe flap, including preparation of recipient site	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15002	Surgical 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 children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15003	Surgical 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15004	Surgical 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 children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15005	Surgical 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15040	Harvest of skin for tissue cultured skin autograft, 100 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15050	Pinch 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 diameter	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15101	Split-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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15110	Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15111	Epidermal 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15115	Epidermal 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	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15116	Epidermal 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15120	Split-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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15121	Split-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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15130	Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15131	Dermal 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15135	Dermal 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	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15136	Dermal 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15150	Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15151	Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15152	Tissue 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15155	Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15156	Tissue 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15157	Tissue 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15200	Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15201	Full 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15220	Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15221	Full 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15240	Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15241	Full 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15260	Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15261	Full 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
15271	Application 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 area	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15272	Application 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15273	Application 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 children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15274	Application 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15275	Application 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 area	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15276	Application 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15277	Application 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 children	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15278	Application 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15570	Formation of direct or tubed pedicle, with or without transfer; trunk	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15572	Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15574	Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15576	Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15600	Delay of flap or sectioning of flap (division and inset); at trunk	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15610	Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15620	Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15630	Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15650	Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15730	Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15731	Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15733	Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15734	Muscle, myocutaneous, or fasciocutaneous flap; trunk	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15736	Muscle, myocutaneous, or fasciocutaneous flap; upper extremity	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15738	Muscle, myocutaneous, or fasciocutaneous flap; lower extremity	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15740	Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15750	Flap; neurovascular pedicle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15756	Free muscle or myocutaneous flap with microvascular anastomosis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15757	Free skin flap with microvascular anastomosis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15758	Free fascial flap with microvascular anastomosis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15760	Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15770	Graft; derma-fat-fascia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15777	Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15780	Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15781	Dermabrasion; segmental, face	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15782	Dermabrasion; regional, other than face	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15783	Dermabrasion; superficial, any site (eg, tattoo removal)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15786	Abrasion; single lesion (eg, keratosis, scar)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15787	Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15788	Chemical peel, facial; epidermal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15789	Chemical peel, facial; dermal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15792	Chemical peel, nonfacial; epidermal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15793	Chemical peel, nonfacial; dermal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15819	Cervicoplasty	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15820	Blepharoplasty, lower eyelid	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15822	Blepharoplasty, upper eyelid;	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15840	Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
15841	Graft for facial nerve paralysis; free muscle graft (including obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15842	Graft for facial nerve paralysis; free muscle flap by microsurgical technique	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15845	Graft for facial nerve paralysis; regional muscle transfer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15850	Removal of sutures under anesthesia (other than local), same surgeon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15851	Removal of sutures under anesthesia (other than local), other surgeon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15852	Dressing change (for other than burns) under anesthesia (other than local)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15860	Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15920	Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15922	Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15931	Excision, sacral pressure ulcer, with primary suture;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15933	Excision, sacral pressure ulcer, with primary suture; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15934	Excision, sacral pressure ulcer, with skin flap closure;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15935	Excision, sacral pressure ulcer, with skin flap closure; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15936	Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15937	Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15940	Excision, ischial pressure ulcer, with primary suture;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15941	Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15944	Excision, ischial pressure ulcer, with skin flap closure;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15945	Excision, ischial pressure ulcer, with skin flap closure; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15946	Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15950	Excision, trochanteric pressure ulcer, with primary suture;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15951	Excision, trochanteric pressure ulcer, with primary suture; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15952	Excision, trochanteric pressure ulcer, with skin flap closure;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15953	Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15956	Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15958	Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
15999	Unlisted procedure, excision pressure ulcer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16000	Initial treatment, first degree burn, when no more than local treatment is required	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16020	Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16025	Dressings 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16030	Dressings 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16035	Escharotomy; initial incision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
16036	Escharotomy; each additional incision (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17000	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17003	Destruction (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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17004	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17106	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17107	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17110	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17111	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17250	Chemical cauterization of granulation tissue (ie, proud flesh)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17260	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17261	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17262	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17263	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17264	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17266	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17270	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17271	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17272	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17273	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17274	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17276	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17280	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17281	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17282	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17283	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17284	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17286	Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17311	Mohs 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 blocks	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17312	Mohs 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17313	Mohs 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 blocks	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17314	Mohs 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17315	Mohs 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
17360	Chemical exfoliation for acne (eg, acne paste, acid)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
19000	Puncture aspiration of cyst of breast;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19001	Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19020	Mastotomy with exploration or drainage of abscess, deep	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19030	Injection procedure only for mammary ductogram or galactogram	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19081	Biopsy, 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 guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19082	Biopsy, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19083	Biopsy, 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 guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19084	Biopsy, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19085	Biopsy, 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 guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19086	Biopsy, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19100	Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19101	Biopsy of breast; open, incisional	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19105	Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19110	Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19112	Excision of lactiferous duct fistula	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19120	Excision 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 lesions	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19125	Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19126	Excision 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19281	Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19282	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19283	Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19284	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19285	Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19286	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19287	Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19288	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19294	Preparation 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19296	Placement 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 mastectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19297	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19298	Placement 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 guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
19300	Mastectomy for gynecomastia	See Comment	See Comment	Non-covered Benefit	Must have diagnosis N62	Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
19301	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19302	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19303	Mastectomy, simple, complete	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19305	Mastectomy, radical, including pectoral muscles, axillary lymph nodes	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19306	Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19307	Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19316	Mastopexy	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19318	Breast reduction	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19325	Breast augmentation with implant	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19328	Removal of intact breast implant	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19330	Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19340	Insertion of breast implant on same day of mastectomy (ie, immediate)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19342	Insertion or replacement of breast implant on separate day from mastectomy	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19350	Nipple/areola reconstruction	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19355	Correction of inverted nipples	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19361	Breast reconstruction; with latissimus dorsi flap	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19364	Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19367	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19368	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19369	Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19370	Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19371	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19380	Revision 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)	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19396	Preparation of moulage for custom breast implant	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
19499	Unlisted procedure, breast	Yes	Yes	Non-covered Benefit		Breast Reduction e-form	Other Hospital Outpatient	Referral- Breast Reduction (Outpatient) Female
20100	Exploration of penetrating wound (separate procedure); neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20101	Exploration of penetrating wound (separate procedure); chest	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20102	Exploration of penetrating wound (separate procedure); abdomen/flank/back	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20103	Exploration of penetrating wound (separate procedure); extremity	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20150	Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20200	Biopsy, muscle; superficial	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20205	Biopsy, muscle; deep	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20206	Biopsy, muscle, percutaneous needle	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20220	Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20240	Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20245	Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20500	Injection of sinus tract; therapeutic (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20501	Injection of sinus tract; diagnostic (sinogram)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20520	Removal of foreign body in muscle or tendon sheath; simple	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20525	Removal of foreign body in muscle or tendon sheath; deep or complicated	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20526	Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20527	Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20550	Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20551	Injection(s); single tendon origin/insertion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20555	Placement 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20561	Needle insertion(s) without injection(s); 3 or more muscles	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20600	Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20604	Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20606	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20610	Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20611	Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20612	Aspiration and/or injection of ganglion cyst(s) any location	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20615	Aspiration and injection for treatment of bone cyst	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20650	Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20660	Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20661	Application of halo, including removal; cranial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20662	Application of halo, including removal; pelvic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20663	Application of halo, including removal; femoral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20664	Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20665	Removal of tongs or halo applied by another individual	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20670	Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20680	Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20690	Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20692	Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20693	Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s])	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20694	Removal, under anesthesia, of external fixation system	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20696	Application 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20697	Application 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, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20700	Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20701	Removal of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20702	Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20703	Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20704	Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20705	Removal of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20802	Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20805	Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20808	Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20816	Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20822	Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20824	Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20827	Replantation, thumb (includes distal tip to MP joint), complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20838	Replantation, foot, complete amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20900	Bone graft, any donor area; minor or small (eg, dowel or button)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20902	Bone graft, any donor area; major or large	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20910	Cartilage graft; costochondral	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
20912	Cartilage graft; nasal septum	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20920	Fascia lata graft; by stripper	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20922	Fascia lata graft; by incision and area exposure, complex or sheet	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20924	Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20930	Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20931	Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20932	Allograft, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20933	Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20934	Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20936	Autograft 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20937	Autograft 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20938	Autograft 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20939	Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20950	Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20955	Bone graft with microvascular anastomosis; fibula	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20956	Bone graft with microvascular anastomosis; iliac crest	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20957	Bone graft with microvascular anastomosis; metatarsal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20962	Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20969	Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20970	Free osteocutaneous flap with microvascular anastomosis; iliac crest	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20972	Free osteocutaneous flap with microvascular anastomosis; metatarsal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20973	Free osteocutaneous flap with microvascular anastomosis; great toe with web space	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20974	Electrical stimulation to aid bone healing; noninvasive (nonoperative)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
20975	Electrical stimulation to aid bone healing; invasive (operative)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
20979	Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20982	Ablation 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; radiofrequency	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
20999	Unlisted procedure, musculoskeletal system, general	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21010	Arthrotomy, temporomandibular joint	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21011	Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21012	Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21013	Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21014	Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21015	Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21016	Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21025	Excision of bone (eg, for osteomyelitis or bone abscess); mandible	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21026	Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21029	Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21030	Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21031	Excision of torus mandibularis	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21032	Excision of maxillary torus palatinus	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21034	Excision of malignant tumor of maxilla or zygoma	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21040	Excision of benign tumor or cyst of mandible, by enucleation and/or curettage	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21044	Excision of malignant tumor of mandible	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21045	Excision of malignant tumor of mandible; radical resection	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21046	Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21047	Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21048	Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21049	Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s])	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21050	Condylectomy, temporomandibular joint (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21060	Meniscectomy, partial or complete, temporomandibular joint (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21070	Coronoidectomy (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21076	Impression and custom preparation; surgical obturator prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21077	Impression and custom preparation; orbital prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21078	Impression and custom preparation; interim obturator prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21079	Impression and custom preparation; definitive obturator prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21080	Impression and custom preparation; mandibular resection prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21081	Impression and custom preparation; palatal augmentation prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21082	Impression and custom preparation; palatal lift prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21083	Impression and custom preparation; speech aid prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21084	Impression and custom preparation; oral surgical splint	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21085	Impression and custom preparation; oral surgical splint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21086	Impression and custom preparation; auricular prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21087	Impression and custom preparation; nasal prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21088	Impression and custom preparation; facial prosthesis	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21089	Unlisted maxillofacial prosthetic procedure	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
21100	Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21116	Injection procedure for temporomandibular joint arthrography	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21121	Genioplasty; sliding osteotomy, single piece	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21125	Augmentation, mandibular body or angle; prosthetic material	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21137	Reduction forehead; contouring only	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21138	Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21139	Reduction forehead; contouring and setback of anterior frontal sinus wall	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21143	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21145	Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21146	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21147	Reconstruction 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21150	Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21154	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21155	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21159	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21160	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21172	Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21175	Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21179	Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21180	Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21181	Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21182	Reconstruction 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 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21183	Reconstruction 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 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21184	Reconstruction 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 cm	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21194	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21198	Osteotomy, mandible, segmental;	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21199	Osteotomy, mandible, segmental; with genioglossus advancement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21206	Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21209	Osteoplasty, facial bones; reduction	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21215	Graft, bone; mandible (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21230	Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21235	Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21240	Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21242	Arthroplasty, temporomandibular joint, with allograft	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21243	Arthroplasty, temporomandibular joint, with prosthetic joint replacement	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21244	Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21245	Reconstruction of mandible or maxilla, subperiosteal implant; partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21246	Reconstruction of mandible or maxilla, subperiosteal implant; complete	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21247	Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21248	Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21249	Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21256	Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21260	Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21261	Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21263	Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21267	Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21268	Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21270	Malar augmentation, prosthetic material	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21275	Secondary revision of orbitocraniofacial reconstruction	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21280	Medial canthopexy (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21282	Lateral canthopexy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21295	Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21296	Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21299	Unlisted craniofacial and maxillofacial procedure	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21310	Closed treatment of nasal bone fracture without manipulation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21315	Closed treatment of nasal bone fracture; without stabilization	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21320	Closed treatment of nasal bone fracture; with stabilization	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21325	Open treatment of nasal fracture; uncomplicated	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21330	Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21335	Open treatment of nasal fracture; with concomitant open treatment of fractured septum	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21336	Open treatment of nasal septal fracture, with or without stabilization	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21337	Closed treatment of nasal septal fracture, with or without stabilization	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21338	Open treatment of nasoethmoid fracture; without external fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21339	Open treatment of nasoethmoid fracture; with external fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21340	Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21343	Open treatment of depressed frontal sinus fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21344	Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21345	Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21346	Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21347	Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21348	Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21355	Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21356	Open treatment of depressed zygomatic arch fracture (eg, Gillies approach)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21360	Open treatment of depressed malar fracture, including zygomatic arch and malar tripod	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21365	Open 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 approaches	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21366	Open 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21385	Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21386	Open treatment of orbital floor blowout fracture; periorbital approach	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21387	Open treatment of orbital floor blowout fracture; combined approach	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21390	Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21395	Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21400	Closed treatment of fracture of orbit, except blowout; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21401	Closed treatment of fracture of orbit, except blowout; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21406	Open treatment of fracture of orbit, except blowout; without implant	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21407	Open treatment of fracture of orbit, except blowout; with implant	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21408	Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21421	Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21422	Open treatment of palatal or maxillary fracture (LeFort I type);	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21423	Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21431	Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21432	Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21433	Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21435	Open 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 Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21436	Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21440	Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21445	Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21450	Closed treatment of mandibular fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21451	Closed treatment of mandibular fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21452	Percutaneous treatment of mandibular fracture, with external fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21453	Closed treatment of mandibular fracture with interdental fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21454	Open treatment of mandibular fracture with external fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21462	Open treatment of mandibular fracture; with interdental fixation	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21465	Open treatment of mandibular condylar fracture	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21470	Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21480	Closed treatment of temporomandibular dislocation; initial or subsequent	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21485	Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21497	Interdental wiring, for condition other than fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21499	Unlisted musculoskeletal procedure, head	See Comment	See Comment	Non-Covered Benefit	Authorization is required when services are being provided by specialty type Oral & Maxillofacial Surgery or an Out of Network Provider	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Oral Surgery or Referral- Outpatient Surgery and Procedures Other OON
21501	Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21502	Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21510	Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21550	Biopsy, soft tissue of neck or thorax	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21552	Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21554	Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21555	Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21556	Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21557	Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21558	Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21600	Excision of rib, partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21601	Excision of chest wall tumor including rib(s)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21602	Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal lymphadenectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21603	Excision of chest wall tumor involving rib(s), with plastic reconstruction; with mediastinal lymphadenectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21610	Costotransversectomy (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21615	Excision first and/or cervical rib;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21616	Excision first and/or cervical rib; with sympathectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21620	Ostectomy of sternum, partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21627	Sternal debridement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21630	Radical resection of sternum;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21632	Radical resection of sternum; with mediastinal lymphadenectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21685	Hyoid myotomy and suspension	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21700	Division of scalenus anticus; without resection of cervical rib	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21705	Division of scalenus anticus; with resection of cervical rib	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21720	Division of sternocleidomastoid for torticollis, open operation; without cast application	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21725	Division of sternocleidomastoid for torticollis, open operation; with cast application	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21740	Reconstructive repair of pectus excavatum or carinatum; open	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21742	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21743	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21750	Closure of median sternotomy separation with or without debridement (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21811	Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21812	Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21813	Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21820	Closed treatment of sternum fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21825	Open treatment of sternum fracture with or without skeletal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21899	Unlisted procedure, neck or thorax	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21920	Biopsy, soft tissue of back or flank; superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21925	Biopsy, soft tissue of back or flank; deep	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21930	Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21931	Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21932	Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21933	Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21935	Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
21936	Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22010	Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22015	Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22100	Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22101	Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22102	Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22103	Partial 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22110	Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22112	Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22114	Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22116	Partial 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22206	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22207	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22208	Osteotomy 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22212	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22214	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22216	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22220	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22222	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22224	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22226	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22310	Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22315	Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22318	Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22319	Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22325	Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22326	Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22327	Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22328	Open 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22505	Manipulation of spine requiring anesthesia, any region	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22510	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22511	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22512	Percutaneous 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22513	Percutaneous 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; thoracic	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22514	Percutaneous 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; lumbar	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22515	Percutaneous 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)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22526	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22527	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22532	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22533	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22534	Arthrodesis, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22552	Arthrodesis, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22556	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22558	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22585	Arthrodesis, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22590	Arthrodesis, posterior technique, craniocervical (occiput-C2)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22595	Arthrodesis, posterior technique, atlas-axis (C1-C2)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22600	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22610	Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22612	Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22614	Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22630	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22632	Arthrodesis, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22633	Arthrodesis, 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; lumbar	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22634	Arthrodesis, 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)	Yes	Yes	Non-Covered Benefit		Outpatient Surgery e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures (Other)
22800	Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22802	Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22804	Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22808	Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22810	Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22812	Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22818	Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22819	Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22830	Exploration of spinal fusion	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22840	Posterior 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22841	Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22842	Posterior 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22843	Posterior 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22844	Posterior 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22845	Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22846	Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22847	Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22848	Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22849	Reinsertion of spinal fixation device	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22850	Removal of posterior nonsegmental instrumentation (eg, Harrington rod)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22852	Removal of posterior segmental instrumentation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22853	Insertion 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22854	Insertion 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22855	Removal of anterior instrumentation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22856	Total 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, cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22857	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22858	Total 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22859	Insertion 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22862	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22864	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22865	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22867	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22868	Insertion 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22869	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22870	Insertion 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22899	Unlisted procedure, spine	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22900	Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22901	Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22902	Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22903	Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22904	Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22905	Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
22999	Unlisted procedure, abdomen, musculoskeletal system	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23000	Removal of subdeltoid calcareous deposits, open	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23020	Capsular contracture release (eg, Sever type procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23030	Incision and drainage, shoulder area; deep abscess or hematoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23031	Incision and drainage, shoulder area; infected bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23035	Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23040	Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23044	Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23065	Biopsy, soft tissue of shoulder area; superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23066	Biopsy, soft tissue of shoulder area; deep	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23071	Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23073	Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23075	Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23076	Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23077	Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23078	Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23100	Arthrotomy, glenohumeral joint, including biopsy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23101	Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23105	Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23106	Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23107	Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23120	Claviculectomy; partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23125	Claviculectomy; total	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23130	Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23140	Excision or curettage of bone cyst or benign tumor of clavicle or scapula;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23145	Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23146	Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23150	Excision or curettage of bone cyst or benign tumor of proximal humerus;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23155	Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23156	Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23170	Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23172	Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23174	Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23180	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23182	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23184	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23190	Ostectomy of scapula, partial (eg, superior medial angle)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23195	Resection, humeral head	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23200	Radical resection of tumor; clavicle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23210	Radical resection of tumor; scapula	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23220	Radical resection of tumor, proximal humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23330	Removal of foreign body, shoulder; subcutaneous	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23333	Removal of foreign body, shoulder; deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23334	Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23335	Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23350	Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23395	Muscle transfer, any type, shoulder or upper arm; single	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23397	Muscle transfer, any type, shoulder or upper arm; multiple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23400	Scapulopexy (eg, Sprengels deformity or for paralysis)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23405	Tenotomy, shoulder area; single tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23406	Tenotomy, shoulder area; multiple tendons through same incision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23410	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23412	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23415	Coracoacromial ligament release, with or without acromioplasty	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23420	Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23430	Tenodesis of long tendon of biceps	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23440	Resection or transplantation of long tendon of biceps	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23450	Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23455	Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23460	Capsulorrhaphy, anterior, any type; with bone block	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23462	Capsulorrhaphy, anterior, any type; with coracoid process transfer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23465	Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23466	Capsulorrhaphy, glenohumeral joint, any type multi-directional instability	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23470	Arthroplasty, glenohumeral joint; hemiarthroplasty	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23473	Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23474	Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23480	Osteotomy, clavicle, with or without internal fixation;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23485	Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23490	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23491	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23500	Closed treatment of clavicular fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23505	Closed treatment of clavicular fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23515	Open treatment of clavicular fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23520	Closed treatment of sternoclavicular dislocation; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23525	Closed treatment of sternoclavicular dislocation; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23530	Open treatment of sternoclavicular dislocation, acute or chronic;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23532	Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23540	Closed treatment of acromioclavicular dislocation; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23545	Closed treatment of acromioclavicular dislocation; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23550	Open treatment of acromioclavicular dislocation, acute or chronic;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23552	Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23570	Closed treatment of scapular fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23575	Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23585	Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23600	Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23605	Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23615	Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23616	Open 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 replacement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23620	Closed treatment of greater humeral tuberosity fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23625	Closed treatment of greater humeral tuberosity fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23630	Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23650	Closed treatment of shoulder dislocation, with manipulation; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23655	Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23660	Open treatment of acute shoulder dislocation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23665	Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23670	Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23675	Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23680	Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23800	Arthrodesis, glenohumeral joint;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23802	Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23900	Interthoracoscapular amputation (forequarter)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23920	Disarticulation of shoulder;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23921	Disarticulation of shoulder; secondary closure or scar revision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23929	Unlisted procedure, shoulder	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23930	Incision and drainage, upper arm or elbow area; deep abscess or hematoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23931	Incision and drainage, upper arm or elbow area; bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
23935	Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24000	Arthrotomy, elbow, including exploration, drainage, or removal of foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24006	Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24065	Biopsy, soft tissue of upper arm or elbow area; superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24066	Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24071	Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24073	Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24075	Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24076	Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24077	Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24079	Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24100	Arthrotomy, elbow; with synovial biopsy only	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24101	Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24102	Arthrotomy, elbow; with synovectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24105	Excision, olecranon bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24110	Excision or curettage of bone cyst or benign tumor, humerus;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24115	Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24116	Excision or curettage of bone cyst or benign tumor, humerus; with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24120	Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24125	Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24126	Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24130	Excision, radial head	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24134	Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24136	Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24138	Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24140	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24145	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24147	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24149	Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24150	Radical resection of tumor, shaft or distal humerus	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24152	Radical resection of tumor, radial head or neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24155	Resection of elbow joint (arthrectomy)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24160	Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24164	Removal of prosthesis, includes debridement and synovectomy when performed; radial head	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24200	Removal of foreign body, upper arm or elbow area; subcutaneous	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24201	Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24220	Injection procedure for elbow arthrography	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24300	Manipulation, elbow, under anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24301	Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24305	Tendon lengthening, upper arm or elbow, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24310	Tenotomy, open, elbow to shoulder, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24320	Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24330	Flexor-plasty, elbow (eg, Steindler type advancement);	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24331	Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24332	Tenolysis, triceps	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24340	Tenodesis of biceps tendon at elbow (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24341	Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24342	Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24343	Repair lateral collateral ligament, elbow, with local tissue	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24344	Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24345	Repair medial collateral ligament, elbow, with local tissue	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24346	Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24357	Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24358	Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24359	Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24360	Arthroplasty, elbow; with membrane (eg, fascial)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24361	Arthroplasty, elbow; with distal humeral prosthetic replacement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24362	Arthroplasty, elbow; with implant and fascia lata ligament reconstruction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24363	Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24365	Arthroplasty, radial head;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24366	Arthroplasty, radial head; with implant	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24370	Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24371	Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24400	Osteotomy, humerus, with or without internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24410	Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24420	Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24430	Repair of nonunion or malunion, humerus; without graft (eg, compression technique)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24435	Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24470	Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24495	Decompression fasciotomy, forearm, with brachial artery exploration	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24498	Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24500	Closed treatment of humeral shaft fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24505	Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24515	Open treatment of humeral shaft fracture with plate/screws, with or without cerclage	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24516	Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24530	Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24535	Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24538	Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24545	Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24546	Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extension	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24560	Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24565	Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24566	Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24575	Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24576	Closed treatment of humeral condylar fracture, medial or lateral; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24577	Closed treatment of humeral condylar fracture, medial or lateral; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24579	Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24582	Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24586	Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius);	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24587	Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24600	Treatment of closed elbow dislocation; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24605	Treatment of closed elbow dislocation; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24615	Open treatment of acute or chronic elbow dislocation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24620	Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24635	Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24640	Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24650	Closed treatment of radial head or neck fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24655	Closed treatment of radial head or neck fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24665	Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24666	Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24670	Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24675	Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24685	Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24800	Arthrodesis, elbow joint; local	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24802	Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24900	Amputation, arm through humerus; with primary closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24920	Amputation, arm through humerus; open, circular (guillotine)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24925	Amputation, arm through humerus; secondary closure or scar revision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24930	Amputation, arm through humerus; re-amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24931	Amputation, arm through humerus; with implant	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24935	Stump elongation, upper extremity	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24940	Cineplasty, upper extremity, complete procedure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
24999	Unlisted procedure, humerus or elbow	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25000	Incision, extensor tendon sheath, wrist (eg, deQuervains disease)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25001	Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25020	Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25023	Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25024	Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25025	Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25028	Incision and drainage, forearm and/or wrist; deep abscess or hematoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25031	Incision and drainage, forearm and/or wrist; bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25035	Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25040	Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25065	Biopsy, soft tissue of forearm and/or wrist; superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25066	Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25071	Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25073	Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25075	Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25076	Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25077	Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25078	Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25085	Capsulotomy, wrist (eg, contracture)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25100	Arthrotomy, wrist joint; with biopsy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25101	Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25105	Arthrotomy, wrist joint; with synovectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25107	Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25109	Excision of tendon, forearm and/or wrist, flexor or extensor, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25110	Excision, lesion of tendon sheath, forearm and/or wrist	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25111	Excision of ganglion, wrist (dorsal or volar); primary	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25112	Excision of ganglion, wrist (dorsal or volar); recurrent	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25115	Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25116	Radical 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 retinaculum	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25118	Synovectomy, extensor tendon sheath, wrist, single compartment;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25119	Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25120	Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process);	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25125	Excision 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25126	Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25130	Excision or curettage of bone cyst or benign tumor of carpal bones;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25135	Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25136	Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25145	Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25150	Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25151	Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25170	Radical resection of tumor, radius or ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25210	Carpectomy; 1 bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25215	Carpectomy; all bones of proximal row	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25230	Radial styloidectomy (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25240	Excision distal ulna partial or complete (eg, Darrach type or matched resection)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25246	Injection procedure for wrist arthrography	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25248	Exploration with removal of deep foreign body, forearm or wrist	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25250	Removal of wrist prosthesis; (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25251	Removal of wrist prosthesis; complicated, including total wrist	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25259	Manipulation, wrist, under anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25260	Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25263	Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25265	Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25270	Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25272	Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25274	Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25275	Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25280	Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25290	Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25295	Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25300	Tenodesis at wrist; flexors of fingers	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25301	Tenodesis at wrist; extensors of fingers	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25310	Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25312	Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25315	Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25316	Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25320	Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25332	Arthroplasty, wrist, with or without interposition, with or without external or internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25335	Centralization of wrist on ulna (eg, radial club hand)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25337	Reconstruction 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 joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25350	Osteotomy, radius; distal third	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25355	Osteotomy, radius; middle or proximal third	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25360	Osteotomy; ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25365	Osteotomy; radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25370	Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25375	Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25390	Osteoplasty, radius OR ulna; shortening	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25391	Osteoplasty, radius OR ulna; lengthening with autograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25392	Osteoplasty, radius AND ulna; shortening (excluding 64876)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25393	Osteoplasty, radius AND ulna; lengthening with autograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25394	Osteoplasty, carpal bone, shortening	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25400	Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25405	Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25415	Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25420	Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25425	Repair of defect with autograft; radius OR ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25426	Repair of defect with autograft; radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25430	Insertion of vascular pedicle into carpal bone (eg, Hori procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25431	Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25440	Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25441	Arthroplasty with prosthetic replacement; distal radius	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25442	Arthroplasty with prosthetic replacement; distal ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25443	Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25444	Arthroplasty with prosthetic replacement; lunate	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25445	Arthroplasty with prosthetic replacement; trapezium	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25447	Arthroplasty, interposition, intercarpal or carpometacarpal joints	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25449	Revision of arthroplasty, including removal of implant, wrist joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25450	Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25455	Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25490	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25491	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25492	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25500	Closed treatment of radial shaft fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25505	Closed treatment of radial shaft fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25515	Open treatment of radial shaft fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25520	Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25525	Open 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 performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25526	Open 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 complex	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25530	Closed treatment of ulnar shaft fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25535	Closed treatment of ulnar shaft fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25545	Open treatment of ulnar shaft fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25560	Closed treatment of radial and ulnar shaft fractures; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25565	Closed treatment of radial and ulnar shaft fractures; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25574	Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25575	Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25600	Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25605	Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25606	Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25607	Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25608	Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25609	Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25622	Closed treatment of carpal scaphoid (navicular) fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25624	Closed treatment of carpal scaphoid (navicular) fracture; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25628	Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25630	Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25635	Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25645	Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25650	Closed treatment of ulnar styloid fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25651	Percutaneous skeletal fixation of ulnar styloid fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25652	Open treatment of ulnar styloid fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25660	Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25670	Open treatment of radiocarpal or intercarpal dislocation, 1 or more bones	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25671	Percutaneous skeletal fixation of distal radioulnar dislocation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25675	Closed treatment of distal radioulnar dislocation with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25676	Open treatment of distal radioulnar dislocation, acute or chronic	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25680	Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25685	Open treatment of trans-scaphoperilunar type of fracture dislocation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25690	Closed treatment of lunate dislocation, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25695	Open treatment of lunate dislocation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25800	Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25805	Arthrodesis, wrist; with sliding graft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25810	Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25820	Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25825	Arthrodesis, wrist; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25830	Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25900	Amputation, forearm, through radius and ulna;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25905	Amputation, forearm, through radius and ulna; open, circular (guillotine)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25907	Amputation, forearm, through radius and ulna; secondary closure or scar revision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25909	Amputation, forearm, through radius and ulna; re-amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25915	Krukenberg procedure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25920	Disarticulation through wrist;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25922	Disarticulation through wrist; secondary closure or scar revision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25924	Disarticulation through wrist; re-amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25927	Transmetacarpal amputation;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25929	Transmetacarpal amputation; secondary closure or scar revision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25931	Transmetacarpal amputation; re-amputation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
25999	Unlisted procedure, forearm or wrist	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26010	Drainage of finger abscess; simple	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26011	Drainage of finger abscess; complicated (eg, felon)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26020	Drainage of tendon sheath, digit and/or palm, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26025	Drainage of palmar bursa; single, bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26030	Drainage of palmar bursa; multiple bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26034	Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26035	Decompression fingers and/or hand, injection injury (eg, grease gun)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26037	Decompressive fasciotomy, hand (excludes 26035)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26040	Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26045	Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26055	Tendon sheath incision (eg, for trigger finger)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26060	Tenotomy, percutaneous, single, each digit	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26070	Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26075	Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26080	Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26100	Arthrotomy with biopsy; carpometacarpal joint, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26105	Arthrotomy with biopsy; metacarpophalangeal joint, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26110	Arthrotomy with biopsy; interphalangeal joint, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26111	Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26113	Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); 1.5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26115	Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26116	Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26117	Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26118	Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26121	Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26123	Fasciectomy, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26125	Fasciectomy, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26130	Synovectomy, carpometacarpal joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26135	Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26140	Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26145	Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26160	Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26170	Excision of tendon, palm, flexor or extensor, single, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26180	Excision of tendon, finger, flexor or extensor, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26185	Sesamoidectomy, thumb or finger (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26200	Excision or curettage of bone cyst or benign tumor of metacarpal;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26205	Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26210	Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26215	Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26230	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26235	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26236	Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26250	Radical resection of tumor, metacarpal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26260	Radical resection of tumor, proximal or middle phalanx of finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26262	Radical resection of tumor, distal phalanx of finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26320	Removal of implant from finger or hand	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26340	Manipulation, finger joint, under anesthesia, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26341	Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26350	Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26352	Repair 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 tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26356	Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26357	Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26358	Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26370	Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26372	Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26373	Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26390	Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26392	Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26410	Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26412	Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26415	Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26416	Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26418	Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26420	Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26426	Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26428	Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26432	Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26433	Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26434	Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26437	Realignment of extensor tendon, hand, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26440	Tenolysis, flexor tendon; palm OR finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26442	Tenolysis, flexor tendon; palm AND finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26445	Tenolysis, extensor tendon, hand OR finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26449	Tenolysis, complex, extensor tendon, finger, including forearm, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26450	Tenotomy, flexor, palm, open, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26455	Tenotomy, flexor, finger, open, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26460	Tenotomy, extensor, hand or finger, open, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26471	Tenodesis; of proximal interphalangeal joint, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26474	Tenodesis; of distal joint, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26476	Lengthening of tendon, extensor, hand or finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26477	Shortening of tendon, extensor, hand or finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26478	Lengthening of tendon, flexor, hand or finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26479	Shortening of tendon, flexor, hand or finger, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26480	Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26483	Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26485	Transfer or transplant of tendon, palmar; without free tendon graft, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26489	Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26490	Opponensplasty; superficialis tendon transfer type, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26492	Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26494	Opponensplasty; hypothenar muscle transfer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26496	Opponensplasty; other methods	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26497	Transfer of tendon to restore intrinsic function; ring and small finger	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26498	Transfer of tendon to restore intrinsic function; all 4 fingers	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26499	Correction claw finger, other methods	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26500	Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26502	Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26508	Release of thenar muscle(s) (eg, thumb contracture)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26510	Cross intrinsic transfer, each tendon	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26516	Capsulodesis, metacarpophalangeal joint; single digit	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26517	Capsulodesis, metacarpophalangeal joint; 2 digits	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26518	Capsulodesis, metacarpophalangeal joint; 3 or 4 digits	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26520	Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26525	Capsulectomy or capsulotomy; interphalangeal joint, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26530	Arthroplasty, metacarpophalangeal joint; each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26531	Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26535	Arthroplasty, interphalangeal joint; each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26536	Arthroplasty, interphalangeal joint; with prosthetic implant, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26540	Repair of collateral ligament, metacarpophalangeal or interphalangeal joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26541	Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26542	Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26545	Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26546	Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26548	Repair and reconstruction, finger, volar plate, interphalangeal joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26550	Pollicization of a digit	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26551	Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26553	Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26554	Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26555	Transfer, finger to another position without microvascular anastomosis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26556	Transfer, free toe joint, with microvascular anastomosis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26560	Repair of syndactyly (web finger) each web space; with skin flaps	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26561	Repair of syndactyly (web finger) each web space; with skin flaps and grafts	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26562	Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26565	Osteotomy; metacarpal, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26567	Osteotomy; phalanx of finger, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26568	Osteoplasty, lengthening, metacarpal or phalanx	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26580	Repair cleft hand	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26587	Reconstruction of polydactylous digit, soft tissue and bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26590	Repair macrodactylia, each digit	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26591	Repair, intrinsic muscles of hand, each muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26593	Release, intrinsic muscles of hand, each muscle	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26596	Excision of constricting ring of finger, with multiple Z-plasties	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26600	Closed treatment of metacarpal fracture, single; without manipulation, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26605	Closed treatment of metacarpal fracture, single; with manipulation, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26607	Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26608	Percutaneous skeletal fixation of metacarpal fracture, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26615	Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26641	Closed treatment of carpometacarpal dislocation, thumb, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26645	Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26650	Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26665	Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26670	Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26675	Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26676	Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26685	Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26686	Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26700	Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26705	Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26706	Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26715	Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26720	Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26725	Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26727	Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26735	Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26740	Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26742	Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26746	Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26750	Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26755	Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26756	Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26765	Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26770	Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26775	Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26776	Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26785	Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26820	Fusion in opposition, thumb, with autogenous graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26841	Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26842	Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26843	Arthrodesis, carpometacarpal joint, digit, other than thumb, each;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26844	Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26850	Arthrodesis, metacarpophalangeal joint, with or without internal fixation;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26852	Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26860	Arthrodesis, interphalangeal joint, with or without internal fixation;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26861	Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26862	Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26863	Arthrodesis, 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26910	Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26951	Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26952	Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26989	Unlisted procedure, hands or fingers	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26990	Incision and drainage, pelvis or hip joint area; deep abscess or hematoma	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26991	Incision and drainage, pelvis or hip joint area; infected bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
26992	Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27000	Tenotomy, adductor of hip, percutaneous (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27001	Tenotomy, adductor of hip, open	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27003	Tenotomy, adductor, subcutaneous, open, with obturator neurectomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27005	Tenotomy, hip flexor(s), open (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27006	Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27025	Fasciotomy, hip or thigh, any type	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27027	Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27030	Arthrotomy, hip, with drainage (eg, infection)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27033	Arthrotomy, hip, including exploration or removal of loose or foreign body	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27035	Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27036	Capsulectomy 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27040	Biopsy, soft tissue of pelvis and hip area; superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27041	Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27043	Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27045	Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27047	Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27048	Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27049	Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27050	Arthrotomy, with biopsy; sacroiliac joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27052	Arthrotomy, with biopsy; hip joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27054	Arthrotomy with synovectomy, hip joint	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27057	Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateral	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27059	Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27060	Excision; ischial bursa	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27062	Excision; trochanteric bursa or calcification	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27065	Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27066	Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27067	Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incision	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27070	Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27071	Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27075	Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27076	Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulum	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27077	Radical resection of tumor; innominate bone, total	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27078	Radical resection of tumor; ischial tuberosity and greater trochanter of femur	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27080	Coccygectomy, primary	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27086	Removal of foreign body, pelvis or hip; subcutaneous tissue	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27087	Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27090	Removal of hip prosthesis; (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27091	Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27093	Injection procedure for hip arthrography; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27095	Injection procedure for hip arthrography; with anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27096	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed	Yes	Yes	Non-covered Benefit		Pain Managament Request e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Pain Management
27097	Release or recession, hamstring, proximal	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27098	Transfer, adductor to ischium	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27100	Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27105	Transfer paraspinal muscle to hip (includes fascial or tendon extension graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27110	Transfer iliopsoas; to greater trochanter of femur	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27111	Transfer iliopsoas; to femoral neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27120	Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27122	Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27125	Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27132	Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27134	Revision of total hip arthroplasty; both components, with or without autograft or allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27137	Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27138	Revision of total hip arthroplasty; femoral component only, with or without allograft	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27140	Osteotomy and transfer of greater trochanter of femur (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27146	Osteotomy, iliac, acetabular or innominate bone;	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27147	Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27151	Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27156	Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27158	Osteotomy, pelvis, bilateral (eg, congenital malformation)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27161	Osteotomy, femoral neck (separate procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27165	Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27170	Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27175	Treatment of slipped femoral epiphysis; by traction, without reduction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27176	Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27177	Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27178	Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27179	Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure)	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27181	Open treatment of slipped femoral epiphysis; osteotomy and internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27185	Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27187	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27197	Closed 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 manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27198	Closed 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27200	Closed treatment of coccygeal fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27202	Open treatment of coccygeal fracture	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27215	Open 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 performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27216	Percutaneous 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27217	Open 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27218	Open 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 Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27220	Closed treatment of acetabulum (hip socket) fracture(s); without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27222	Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27226	Open treatment of posterior or anterior acetabular wall fracture, with internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27227	Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27228	Open 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 fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27230	Closed treatment of femoral fracture, proximal end, neck; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27232	Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27235	Percutaneous skeletal fixation of femoral fracture, proximal end, neck	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27236	Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27238	Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27240	Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27244	Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27245	Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27246	Closed treatment of greater trochanteric fracture, without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27248	Open treatment of greater trochanteric fracture, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27250	Closed treatment of hip dislocation, traumatic; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27252	Closed treatment of hip dislocation, traumatic; requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27253	Open treatment of hip dislocation, traumatic, without internal fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27254	Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27256	Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27257	Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27258	Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc);	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27259	Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27265	Closed treatment of post hip arthroplasty dislocation; without anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27266	Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27267	Closed treatment of femoral fracture, proximal end, head; without manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27268	Closed treatment of femoral fracture, proximal end, head; with manipulation	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27269	Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27275	Manipulation, hip joint, requiring general anesthesia	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON
27279	Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device	See Comment	See Comment	Non-Covered Benefit	In Network: No authorization is required Out of Network:Authorization is required.	Out of Network e-form	Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services	Referral- Outpatient Surgery and Procedures Other OON