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BlueCross BlueShield of Tennessee: Prior Authorization List (PAL) Codes Under Management (UM Tech)

Written by Nicole Saidai

BlueCross BlueShield of Tennessee

Prior Authorization List Codes Under Management:

UM Tech

Overview

We are pleased to share that Cohere Health® is expanding its partnership with BlueCross BlueShield of Tennessee health plans for UM Tech services. Our goal with this partnership is to streamline the prior authorization process for these select services, and enhance the quality of care through evidence-based care paths to help manage a patient’s care journey.

Beginning October 2025, prior authorizations for UM Tech - All In-House (IP & OP) Commercial services can be submitted through the Cohere Health portal.

Impacted Plans and Geographies

Impacted plans and geographies will include BlueCross BlueShield of Tennessee Commercial, for all eligible members.

Clinical Scope

Practices must use Cohere when requesting preauthorizations for any of the procedure codes or services listed in the table below.

Please note that issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to BlueCross BlueShield of Tennessee’s official Prior Authorization Lists (PAL) for the most up to date prior authorization requirements, coverage policies, and related plan policies.

Clinical Service

CPT Codes

ABA

  • 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T

Air Ambulance

  • A0430, A0431, A0435, A0436

Amputation- Penis

  • 54125

Bariatric Surgeries

  • 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888

Behavioral Health

  • G0177

Behaviorial Health-Partial Hospitalizaton

  • S0201

Breast Surgeries for Augmentation and Reduction

  • 19300, 19318, 19340, 19499

Cardiac Devices

  • Q0508, Q0509, E0610, E0615, E0616, E0617, E0620, K0606, K1030, L8670, Q0477, Q0478, Q0479, Q0480, Q0481, Q0482, Q0483, Q0484, Q0485, Q0486, Q0487, Q0488, Q0489, Q0490, Q0491, Q0492, Q0493, Q0494, Q0495, Q0496, Q0497, Q0498, Q0499, Q0500, Q0501, Q0502, Q0503, Q0504, Q0506, Q0507

Cochlear Device Supplies

  • L8614, L8615, L8617, L8618, L8619, L8621, L8622, L8623, L8624, L8625, L8627, L8628, L8629, L8690, L8691, L8692, L8693, L8694

Compression Devices

  • E0565, E0572, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0677, E0678, E0679, E0680, E0681, E0682

Diabetic Supplies

  • A4233, A4234, A4235, A4236, A4255, A9274, A9278, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037

Diagnostic Imaging

  • 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76390, 76391, 77046, 77047, 77048, 77049, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, C9762, C9763, C9791, G0219, G0235, G0252, S8037, S8042, S8092

Dialysis

  • E1615, E1699

DME

  • A4213, A4217, A4220, A4232, A4253, A4322, A4354, A4362, A4371, A4402, A4406, A4414, A4422, A4425, A4452, A4467, A4570, A4604, A4606, A4625, A4628, A5056, A5063, A5102, A5105, A5120, A6021, A6211, A6212, A6213, A6223, A6252, A6402, A6452, A6505, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6545, A6549, A6550, A7002, A7003, A7005, A7015, A7021, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7046, A7521, A9279, A9282, A9508, A9517, B4087, C1767, C1781, C1787, E0105, E0110, E0114, E0117, E0118, E0135, E0140, E0143, E0147, E0148, E0149, E0154, E0155, E0156, E0159, E0163, E0165, E0167, E0168, E0181, E0184, E0188, E0371, E0372, E0469, E0561, E0562, E0607, E0746, E0781, E0910, E0940, E0981, E1015, E1300, E1301, E2213, E2323, E2361, E2365, E2366, E2367, E2398, J0585, L0120, L0170, L0172, L0174, L0180, L0190, L0200, L0450, L0454, L0456, L0457, L0458, L0460, L0462, L0464, L0468, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0621, L0625, L0626, L0627, L0628, L0630, L0631, L0635, L0636, L0637, L0638, L0639, L0640, L0642, L0648, L0649, L0650, L0651, L0810, L0972, L0984, L1000, L1005, L1006, L1010, L1020, L1030, L1040, L1060, L1250, L1260, L1270, L1280, L1290, L1300, L1600, L1640, L1685, L1686, L1690, L1730, L1810, L1812, L1820, L1821, L1830, L1831, L1832, L1833, L1834, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1900, L1902, L1904, L1906, L1907, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2050, L2060, L2108, L2112, L2114, L2116, L2126, L2136, L2180, L2200, L2210, L2220, L2250, L2265, L2275, L2280, L2300, L2320, L2330, L2340, L2350, L2360, L2370, L2385, L2387, L2390, L2395, L2397, L2415, L2425, L2430, L2600, L2620, L2624, L2627, L2628, L2640, L2755, L2760, L2768, L2780, L2785, L2795, L2810, L2820, L2830, L2840, L2850, L3161, L3208, L3211, L3260, L3650, L3660, L3670, L3671, L3674, L3675, L3702, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3905, L3906, L3908, L3912, L3915, L3918, L3919, L3921, L3923, L3924, L3931, L3933, L3960, L3962, L3973, L3980, L3982, L3984, L3995, L4350, L4360, L4361, L4386, L4387, L4396, L4397, L4398, L4631, L5615, L5926, L8035, L8435, L8600, L8678, L8679, S8422, S8427, S9002, V2531, V2623, V2624, V2625, V2626, V2627, V2628, V5110, V5160, V5241, V5254, V5256, V5257, V5258, V5261, V5264, V5275, A4352, A4385, A4394, A4407, A4409, L1200, L1210, L1220, L1230, L1240, L2270, L2405, L3913, L3927, L8015

E & M - Alcohol and Substance Abuse Services

  • H0015, H2035, H2036

E & M - Behavioral Health Services

  • H0035, H2028, H2029, S9480

E & M - Behavioral Health Services-Group Therapy

  • G0410, G0411

E & M - Behavioral Health Services-Neuropsych Testing

  • 96146, 96116

Electrical Stimulation Therapy Supplies

  • A4594, A4596, A4630, E0720, E0730, E0731, E0732, E0733, E0734, E0735, E0739, E0740, E0744, E0745, E0747, E0748, E0749, E0760, E0761, E0762, E0764, E0766, E0769, E0770, L8684, L8695

Endometrial Ablation

  • 58353, 58356, 58563

Excision Procedures - Corpus Uteri

  • 58180, 58150

Excision Procedures - Testis

  • 54520

Excision Procedures- Corpus Uteri

  • 58294, 58260, 58267, 58262, 58263, 58270, 58290, 58291, 58292, 58275, 58280

Excision Procedures- Ovary

  • 58720

Excision Procedures- Vagina

  • 57110, 57106, 57335

Excision Procedures- Vulva/Perineum/Introitus

  • 56625

Facial and External Ear Prosthetics

  • L8040, L8042, L8044, L8045, L8046, L8047, L8048, L8049

Gender Reassignment

  • 19350

Genetic Testing

  • 81162, 81163, 81164, 81165, 81166, 81167, 81173, 81174, 81185, 81186, 81189, 81190, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81434, 81435, 81437, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81479, 81490, 81493, 81500, 81503, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81535, 81536, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81595, 81596, 81599, 86152, 86153, 0001U, 0002U, 0003M, 0004M, 0005U, 0006M, 0007M, 0011M, 0012M, 0012U, 0013M, 0013U, 0014U, 0016M, 0017M, 0018U, 0019U, 0020M, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0056U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0104U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0355U, 0356U, 0362U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0464U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, G0327, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870

Heat, Cold, Light Therapies-DME

  • A4633, A9273, E0200, E0202, E0205, E0210, E0215, E0217, E0225, E0239, E0249, E0691, E0692, E0693, E0694

Home Assist Devices

  • A4640, E0160, E0161, E0162, E0170, E0171, E0172, E0175, E0182, E0183, E0185, E0186, E0187, E0193, E0194, E0196, E0197, E0198, E0199, E0218, E0235, E0236, E0244, E0245, E0247, E0248, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0275, E0276, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0373, E0462, E0621, E0625, E0627, E0629, E0630, E0635, E0636, E0637, E0638, E0639, E0640, E0641, E0642, E0700, E0705, E0911, E0912, E0968, E1031, E1035, E1036, E1037, E1038, E1039, E1355, K0056

Home Health

  • 99503, 0733T

Home Health Services

  • 0734T, G0162, G0299, G0300, G0490, G0493, G0494, G0495, G0496, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99375, 99500, 99501, 99502, 99504, 99505, 99506, 99507, 99509, 99510, 99511, 99512, 99600, 99601, 99602, G0088, G0089, G0090, G0155, G0156, G0320, S0270, S0271, S0272, S0273, S0274, S5108, S5109, S5110, S5111, S5115, S5116, S5120, S5121, S5125, S5126, S9122, S9123, S9124, S9127, S9325, S9326, S9327, S9328, S9329, S9330, S9331, S9335, S9336, S9338, S9339, S9345, S9346, S9347, S9348, S9349, S9351, S9353, S9355, S9357, S9359, S9361, S9363, S9370, S9372, S9373, S9374, S9375, S9376, S9377, S9379, T1021, T1022, T1502, T1503

Hospice Services

  • T2044, T2045

Hyperbaric Oxygen

  • 99183, G0277

Implantable Eye & Ear Prosthetics and Accessories

  • L8609, L8610, L8612

Infusion Pump

  • A4602, E0782, E0783, E0784, E0785, E0786, E0787, E0791, K0455, K0552, K0601, K0602, K0603, K0604, K0605

Infusion Therapy Services & Supplies

  • 96374, 96375, 96376

Intersex Surgery

  • 55980, 55970

Laparoscopy

  • 58570, 58541, 58542, 58543, 58544, 58571, 58572, 58573, 58550, 58552, 58553, 58554, 54690, 58700

Mastectomy

  • 19325, 19303

Medical & Surgical Supplies

  • A4258, A4259, E0602, E0603, E0676, L5400, L5410, L5420, L5430, L5450, L5460, L6380, L6382, L6384, L6388

Misc. DME

  • A4256, A4561, A4562, A4618, A4619, A4638, A9270, A9300, E0189, E0483, E0484, E0710, E0765, E0776, E1310, E1399, E1905, E2120, K0073, K0105, K0462, K0730, K0739, L7009, L7045, L7360, L7362, L7364, L7366, L7367, L7368, Q4045, Q4300, S8130, S8131

Mobility Device

  • A4635, A4636, A4637, E0100, E0111, E0112, E0113, E0116, E0130, E0141, E0144, E0153, E0157, E0158, E0240, E0950, E0953, E0954, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0982, E0983, E0984, E0985, E0986, E0988, E0990, E0992, E0994, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1017, E1020, E1028, E1029, E1030, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1229, E1230, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297, E1298, E2201, E2202, E2203, E2204, E2205, E2206, E2208, E2210, E2211, E2212, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231, E2291, E2292, E2293, E2294, E2295, E2298, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2358, E2359, E2362, E2363, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2402, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K0010, K0011, K0012, K0013, K0014, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0065, K0069, K0070, K0071, K0072, K0077, K0098, K0108, K0195, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, K0900

MSK

  • 20930, 20985, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22836, 22837, 22838, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22849, 22850, 22852, 22853, 22854, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 23040, 23044, 23100, 23101, 23105, 23106, 23107, 23120, 23125, 23130, 23190, 23195, 23333, 23334, 23335, 23410, 23412, 23415, 23420, 23430, 23470, 23472, 23473, 23474, 23800, 23802, 27033, 27090, 27091, 27125, 27130, 27132, 27134, 27137, 27138, 27278, 27279, 27280, 27299, 27331, 27332, 27333, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27428, 27429, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27702, 27703, 28446, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29850, 29851, 29855, 29856, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916, 62287, 62320, 62321, 62322, 62323, 62350, 62351, 62360, 62361, 62362, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64625, 64628, 64629, 64633, 64634, 64635, 64636

MSK Prosthesis/Orthosis/Bracing/Orthotics/Other Stabilization

  • A9283, C1713, E0191, E0457, E0459, E0738, E0942, E0944, E0945, E0951, E0952, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841, E2209, E8000, E8001, E8002, K0672, K1007, L0112, L0220, L0452, L0622, L0624, L0629, L0700, L0710, L0820, L0830, L0859, L0861, L0980, L0982, L0999, L1025, L1050, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1310, L1320, L1499, L1630, L1660, L1680, L1700, L1710, L1720, L1755, L1860, L2005, L2006, L2035, L2040, L2070, L2080, L2090, L2106, L2128, L2132, L2134, L2182, L2184, L2186, L2188, L2190, L2192, L2230, L2232, L2240, L2260, L2310, L2335, L2375, L2380, L2492, L2500, L2525, L2526, L2530, L2540, L2550, L2570, L2622, L2750, L2800, L2999, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3209, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649, L3891, L3904, L3916, L3925, L3935, L3956, L3961, L3967, L3971, L3975, L3976, L3977, L3978, L3981, L3999, L4000, L4002, L4205, L4210, L4370, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5991, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6386, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7040, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7600, L7700, L8041, L8043, L8300, L8310, L8320, L8330, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8465, L8470, L8480, L8485, L8616, L8630, L8631, L8641, L8642, L8658, L8659, L8699, L8701, L8702, L9900, S1040, T5001

Musculoskeletal Pain Managment

  • 0098T, 0164T, 0165T, 0200T, 0201T, 0202T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, 0707T, 0784T, 0785T, 0790T, C1737, C9757, G0289, J7330, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689, S2112, S2118, S2348

Oncology Radiation

  • 19294, 19296, 19297, 19298, 31643, 32533, 41019, 49411, 49412, 55875, 55876, 55920, 57155, 57156, 58346, 61796, 61797, 61798, 61799, 61800, 76873, 76965, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77301, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77371, 77372, 77373, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77417, 77423, 77424, 77425, 77427, 77431, 77432, 77435, 77469, 77470, 77499, 77520, 77522, 77523, 77525, 77600, 77605, 77610, 77615, 77620, 77750, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 77789, 77790, 77799, 79005, 79101, 79403, 0394T, 0395T, 0745T, 0746T, 0747T, A9513, A9543, A9590, A9606, C2616, C9726, G0339, G0340, G0458, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017, S2095, S8030

Oral Device/Appliance

  • E0485, E0486, E0490, E0491, E0492, E0493, E1700, E1701, E1702, K1027, K1037

Other Procedures - Larynx

  • 31599

Other Procedures- Female Genital System

  • 58999

Other Procedures- Male Genital System

  • 55899

Other Procedures- Skin and Mucous Membrane

  • 17999

Other Procedures- Trachea/Bronchi

  • 31899

Other Prosthetics and Accessories

  • L7510, L7520, L8000, L8001, L8020, L8030, L8031, L8039, L8499, L8500, L8505

Other Repair (Closure) - Eyelid

  • 15820, 15821, 15822, 15823, 15824, 15826, 67900

Other Repair (Closure) - Skin

  • 15830, 15839, 15847, 15877

Outpatient Behavioral Health - Psych Testing

  • 96132, 96133

Oxygen supplies or other breathing aids

  • A4614, E0190, E0465, E0466, E0467, E0468, E0470, E0471, E0472, E0480, E0481, E0482, E0500, E0570, E0574, E0575, E0580, E0585, E0600, E1352, E1353, E1372, E1390, E1391, E1392, E1405, E1406

Partial Hospitalization Program

  • H2012, H2013

Penile implant

  • C1813, C2622

Physical, Occupational, and Speech Therapy

  • 92507, 92508, 92520, 92521, 92522, 92523, 92524, 92526, 92527, 92529, 92597, 92601, 92602, 92603, 92604, 92606, 92607, 92608, 92609, 92610, 92614, 92616, 93668, 95851, 95852, 95992, 96000, 96001, 96002, 96004, 96105, 97003, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97037, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97445, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97550, 97551, 97552, 97750, 97755, 97760, 97761, 97763, 97799, 0210T, 0211T, 0212T, G0129, G0151, G0152, G0153, G0237, G0238, G0239, Q0086, S8950, S8990, S9090, S9128, S9129, S9131, S9152, S9476, V5362, V5363, V5364

Proprietary Laboratory Analysis

  • 0210U, 0359U, 0360U, 0361U, 0365U, 0366U, 0367U, 0371U, 0372U

Prostate Resection

  • 55866

Psychological and Neuropsychological Testing

  • 96130, 96131, 96136, 96137, 96138, 96139

Repair Procedures - Scrotum

  • 55180, 55175

Repair Procedures - Testis

  • 54660

Repair Procedures - Vagina

  • 57292, 57291

Repair Procedures - Vulva/Perineum/Introitus

  • 56805, 56800

Repair Procedures- Urethra

  • 53420, 53425, 53430

Residential Rehab

  • H0022

Respite Care Services

  • T1005

Room & Board various levels: Detoxification

  • H0008, H0009, H0010, H0011

Room & Board various levels: Psychiatric

  • H0017, H0018, H0019, T2048

Skilled Nursing Services

  • T1000, T1001, T1002, T1003, T1004, T1030, T1031

Sleep Apnea Device

  • E0530, E0601, E0618, E0619

Sleep Study

  • 95805, 95807, 95808, 95810, 95811

Speech Generating Device

  • E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, E3000, V5336

Therapy

  • 92511, 92605, 92618, 0791T

TMS

  • 90867, 90868, 90869

Tracheostoma Supplies

  • A4605, A4624, L8501, L8507, L8509, L8510, L8511, L8512, L8513, L8514, L8515

Traction Device

  • E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0870, E0880, E0890, E0900, E0920, E0930, E0935, E0936, E0941, E0946, E0947, E0948

Transplant

  • 50360, 32851, 32852, 32853, 32854, 33935, 33945, 33979, 38230, 38232, 38240, 38241, 38242, 47135, 48160, 48554, 50340, 50365, 50380, 65710, 65730, 65750, 65755, 65756, 65765, 65767, 65778, 65779, 0584T, 0585T, 0586T

Tube Feeding Supplies

  • B4034, B4035, B4036, B4081, B4082, B4083, B4088, B4100, B4102, B4103, B4104, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9002, B9004, B9006, B9998, B9999, E2000, S9432, S9433, S9434, S9435

Urological Supplies

  • E0325, E0326, L7900, L7902, L8606

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