Non-Covered Diagnosis Codes

UnitedHealthcare? Medicare Advantage Policy Appendix: Applicable Code List

Non-Covered Diagnosis Codes

This list of codes applies to the Medicare Advantage Policy Guidelines titled:

Last Updated: October 12, 2022

Biomarkers in Cardiovascular Risk Assessment Blood Product Molecular Antigen Typing BRCA1 and BRCA2 Genetic Testing Clinical Diagnostic Laboratory Services Computed Tomography (NCD 220.1) Genetic Testing for Lynch Syndrome Magnetic Resonance Imaging (NCD 220.2)

? Molecular Diagnostic Infectious Disease Testing

? Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing

? Molecular Pathology/ Genetic Testing Reported with Unlisted Codes

? Molecular Pathology/Molecular Diagnostics/Genetic Testing

? Pharmacogenomics Testing ? Tier 2 Molecular Pathology Procedures

? Ultrasound Diagnostic Procedures (NCD 220.5)

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Diagnosis Code Non-Covered

R99 Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 Z00.129 Z00.5 Z00.70 Z00.71 Z00.8 Z02.0 Z02.1 Z02.2 Z02.3 Z02.4

Description

Ill-defined and unknown cause of mortality Encounter for general adult medical examination without abnormal findings Encounter for general adult medical examination with abnormal findings Health examination for newborn under 8 days old Health examination for newborn 8 to 28 days old Encounter for routine child health examination with abnormal findings Encounter for routine child health examination without abnormal findings Encounter for examination of potential donor of organ and tissue Encounter for examination for period of delayed growth in childhood without abnormal findings Encounter for examination for period of delayed growth in childhood with abnormal findings Encounter for other general examination Encounter for examination for admission to educational institution Encounter for pre-employment examination Encounter for examination for admission to residential institution Encounter for examination for recruitment to armed forces Encounter for examination for driving license

Non-Covered Diagnosis Codes

Page 1 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

Diagnosis Code Non-Covered

Z02.5 Z02.6 Z02.71 Z02.79 Z02.81 Z02.82 Z02.83 Z02.89 Z02.9 Z04.6 Z04.81 Z04.82 Z04.89 Z04.9 Z11.0 Z11.1 Z11.2 Z11.3 Z11.4 Z11.51 Z11.59 Z11.6 Z11.7 Z11.8 Z11.9 Z12.0 Z12.10 Z12.13 Z12.2 Z12.6 Z12.71 Z12.72 Z12.73 Z12.79 Z12.81 Z12.82 Z12.83 Z12.89 Z12.9 Z13.0

Description

Encounter for examination for participation in sport Encounter for examination for insurance purposes Encounter for disability determination Encounter for issue of other medical certificate Encounter for paternity testing Encounter for adoption services Encounter for blood-alcohol and blood-drug test Encounter for other administrative examinations Encounter for administrative examinations, unspecified Encounter for general psychiatric examination, requested by authority Encounter for examination and observation of victim following forced sexual exploitation Encounter for examination and observation of victim following forced labor exploitation Encounter for examination and observation for other specified reasons Encounter for examination and observation for unspecified reason Encounter for screening for intestinal infectious diseases Encounter for screening for respiratory tuberculosis Encounter for screening for other bacterial diseases Encounter for screening for infections with a predominantly sexual mode of transmission Encounter for screening for human immunodeficiency virus [HIV] Encounter for screening for human papillomavirus (HPV) Encounter for screening for other viral diseases Encounter for screening for other protozoal diseases and helminthiases Encounter for testing for latent tuberculosis infection Encounter for screening for other infectious and parasitic diseases Encounter for screening for infectious and parasitic diseases, unspecified Encounter for screening for malignant neoplasm of stomach Encounter for screening for malignant neoplasm of intestinal tract, unspecified Encounter for screening for malignant neoplasm of small intestine Encounter for screening for malignant neoplasm of respiratory organs Encounter for screening for malignant neoplasm of bladder Encounter for screening for malignant neoplasm of testis Encounter for screening for malignant neoplasm of vagina Encounter for screening for malignant neoplasm of ovary Encounter for screening for malignant neoplasm of other genitourinary organs Encounter for screening for malignant neoplasm of oral cavity Encounter for screening for malignant neoplasm of nervous system Encounter for screening for malignant neoplasm of skin Encounter for screening for malignant neoplasm of other sites Encounter for screening for malignant neoplasm, site unspecified Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Non-Covered Diagnosis Codes

Page 2 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

Diagnosis Code Non-Covered

Z13.21 Z13.220 Z13.228 Z13.29 Z13.30 Z13.31 Z13.32 Z13.39 Z13.40 Z13.41 Z13.42 Z13.49

Z13.5 Z13.71 Z13.79 Z13.810 Z13.811 Z13.818 Z13.820 Z13.828 Z13.83 Z13.84 Z13.850 Z13.858 Z13.88 Z13.89 Z13.9 Z36.0 Z36.1 Z36.2 Z36.3 Z36.4 Z36.5 Z36.81 Z36.82 Z36.83 Z36.84 Z36.85 Z36.86 Z36.87

Description

Encounter for screening for nutritional disorder Encounter for screening for lipoid disorders Encounter for screening for other metabolic disorders Encounter for screening for other suspected endocrine disorder Encounter for screening examination for mental health and behavioral disorders, unspecified Encounter for screening for depression Encounter for screening for maternal depression Encounter for screening examination for other mental health and behavioral disorders Encounter for screening for unspecified developmental delays Encounter for autism screening Encounter for screening for global developmental delays (milestones) Encounter for screening for other developmental delays Encounter for screening for eye and ear disorders Encounter for nonprocreative screening for genetic disease carrier status Encounter for other screening for genetic and chromosomal anomalies Encounter for screening for upper gastrointestinal disorder Encounter for screening for lower gastrointestinal disorder Encounter for screening for other digestive system disorders Encounter for screening for osteoporosis Encounter for screening for other musculoskeletal disorder Encounter for screening for respiratory disorder NEC Encounter for screening for dental disorders Encounter for screening for traumatic brain injury Encounter for screening for other nervous system disorders Encounter for screening for disorder due to exposure to contaminants Encounter for screening for other disorder Encounter for screening, unspecified Encounter for antenatal screening for chromosomal anomalies Encounter for antenatal screening for raised alphafetoprotein level Encounter for other antenatal screening follow-up Encounter for antenatal screening for malformations Encounter for antenatal screening for fetal growth retardation Encounter for antenatal screening for isoimmunization Encounter for antenatal screening for hydrops fetalis Encounter for antenatal screening for nuchal translucency Encounter for fetal screening for congenital cardiac abnormalities Encounter for antenatal screening for fetal lung maturity Encounter for antenatal screening for Streptococcus B Encounter for antenatal screening for cervical length Encounter for antenatal screening for uncertain dates

Non-Covered Diagnosis Codes

Page 3 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

Diagnosis Code Non-Covered

Z36.88 Z36.89 Z36.8A Z36.9 Z40.00 Z40.01 Z40.02 Z40.09 Z40.8 Z40.9 Z41.1 Z41.2 Z41.3 Z41.8 Z41.9 Z46.1 Z56.0 Z56.2 Z56.3 Z56.4 Z56.5 Z56.6 Z56.81 Z56.82 Z56.89 Z56.9 Z57.0 Z57.1 Z57.2 Z57.31 Z57.39 Z57.4 Z57.5 Z57.6 Z57.7 Z57.8 Z57.9 Z58.6 Z59.0 Z59.00

Description

Encounter for antenatal screening for fetal macrosomia Encounter for other specified antenatal screening Encounter for antenatal screening for other genetic defects Encounter for antenatal screening, unspecified Encounter for prophylactic removal of unspecified organ Encounter for prophylactic removal of breast Encounter for prophylactic removal of ovary(s) Encounter for prophylactic removal of other organ Encounter for other prophylactic surgery Encounter for prophylactic surgery, unspecified Encounter for cosmetic surgery Encounter for routine and ritual male circumcision Encounter for ear piercing Encounter for other procedures for purposes other than remedying health state Encounter for procedure for purposes other than remedying health state, unspecified Encounter for fitting and adjustment of hearing aid Unemployment, unspecified Threat of job loss Stressful work schedule Discord with boss and workmates Uncongenial work environment Other physical and mental strain related to work Sexual harassment on the job Military deployment status Other problems related to employment Unspecified problems related to employment Occupational exposure to noise Occupational exposure to radiation Occupational exposure to dust Occupational exposure to environmental tobacco smoke Occupational exposure to other air contaminants Occupational exposure to toxic agents in agriculture Occupational exposure to toxic agents in other industries Occupational exposure to extreme temperature Occupational exposure to vibration Occupational exposure to other risk factors Occupational exposure to unspecified risk factor Inadequate drinking-water supply (Effective 10/01/2021) Homelessness (Deleted 09/30/2021) Homelessness unspecified (Effective 10/01/2021)

Non-Covered Diagnosis Codes

Page 4 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

Diagnosis Code Non-Covered

Z59.01 Z59.02 Z59.1 Z59.2 Z59.3 Z59.4 Z59.41 Z59.48 Z59.5 Z59.6 Z59.7 Z59.8 Z59.811 Z59.812 Z59.819 Z59.89 Z59.9 Z60.2 Z62.21 Z71.0 Z74.1 Z74.2 Z74.3 Z74.8 Z74.9 Z75.5 Z76.0 Z76.1 Z76.2 Z76.3 Z76.4 Z76.81 Z80.1 Z80.2 Z80.49 Z80.51 Z80.52 Z80.59 Z80.6 Z80.7

Description

Sheltered homelessness (Effective 10/01/2021) Unsheltered homelessness (Effective 10/01/2021) Inadequate housing Discord with neighbors, lodgers and landlord Problems related to living in residential institution Lack of adequate food and safe drinking water (Deleted 09/30/2021) Food insecurity (Effective 10/01/2021) Other specified lack of adequate food (Effective 10/01/2021) Extreme poverty Low income Insufficient social insurance and welfare support Other problems related to housing and economic circumstances (Deleted 09/30/2021) Housing instability, housed, with risk of homelessness (Effective 10/01/2021) Housing instability, housed, homelessness in past 12 months (Effective 10/01/2021) Housing instability, housed unspecified (Effective 10/01/2021) Other problems related to housing and economic circumstances (Effective 10/01/2021) Problem related to housing and economic circumstances, unspecified Problems related to living alone Child in welfare custody Person encountering health services to consult on behalf of another person Need for assistance with personal care Need for assistance at home and no other household member able to render care Need for continuous supervision Other problems related to care provider dependency Problem related to care provider dependency, unspecified Holiday relief care Encounter for issue of repeat prescription Encounter for health supervision and care of foundling Encounter for health supervision and care of other healthy infant and child Healthy person accompanying sick person Other boarder to healthcare facility Expectant parent(s) prebirth pediatrician visit Family history of malignant neoplasm of trachea, bronchus and lung Family history of malignant neoplasm of other respiratory and intrathoracic organs Family history of malignant neoplasm of other genital organs Family history of malignant neoplasm of kidney Family history of malignant neoplasm of bladder Family history of malignant neoplasm of other urinary tract organ Family history of leukemia Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Non-Covered Diagnosis Codes

Page 5 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

Diagnosis Code Non-Covered

Z80.8 Z80.9 Z81.0 Z81.1 Z81.2 Z81.3 Z81.4 Z81.8 Z82.0 Z82.1 Z82.2 Z82.3 Z82.41 Z82.49 Z82.5 Z82.61 Z82.62 Z82.69 Z82.71 Z82.79 Z82.8 Z83.0 Z83.1 Z83.2

Z83.3 Z83.41 Z83.49 Z83.511 Z83.518 Z83.52 Z83.6 Z83.71 Z83.79 Z84.0 Z84.1 Z84.2 Z84.3 Z84.81 Z84.89

Description

Family history of malignant neoplasm of other organs or systems Family history of malignant neoplasm, unspecified Family history of intellectual disabilities Family history of alcohol abuse and dependence Family history of tobacco abuse and dependence Family history of other psychoactive substance abuse and dependence Family history of other substance abuse and dependence Family history of other mental and behavioral disorders Family history of epilepsy and other diseases of the nervous system Family history of blindness and visual loss Family history of deafness and hearing loss Family history of stroke Family history of sudden cardiac death Family history of ischemic heart disease and other diseases of the circulatory system Family history of asthma and other chronic lower respiratory diseases Family history of arthritis Family history of osteoporosis Family history of other diseases of the musculoskeletal system and connective tissue Family history of polycystic kidney Family history of other congenital malformations, deformations and chromosomal abnormalities Family history of other disabilities and chronic diseases leading to disablement, not elsewhere classified Family history of human immunodeficiency virus [HIV] disease Family history of other infectious and parasitic diseases Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Family history of diabetes mellitus Family history of multiple endocrine neoplasia [MEN] syndrome Family history of other endocrine, nutritional and metabolic diseases Family history of glaucoma Family history of other specified eye disorder Family history of ear disorders Family history of other diseases of the respiratory system Family history of colonic polyps Family history of other diseases of the digestive system Family history of diseases of the skin and subcutaneous tissue Family history of disorders of kidney and ureter Family history of other diseases of the genitourinary system Family history of consanguinity Family history of carrier of genetic disease Family history of other specified conditions

Non-Covered Diagnosis Codes

Page 6 of 6

UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List

Approval 10/12/2022

Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.

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