Master Precertification List - Cigna

[Pages:367]0f

MASTER PRECERTIFICATION LIST

For Health Care Providers Effective February 2022

Complete/PHS+ - The most comprehensive care management model that includes all the components of our Preferred level, plus additional digital tools and the highest level of engagement and potential savings.

Preferred - A comprehensive care management model that includes all the components of our existing care management model, including comprehensive outpatient precertification, plus higher intensity of care coordination and more customer engagement opportunities.

Basic Standard - A lower touch care management model that includes many of the components of our existing care management model, such as higher intensity of care coordination and more customer engagement opportunities. Basic Standard has a limited number of outpatient precertification categories (radiation therapy, medical oncology, medical injectables, home infusion therapy and private duty nursing), fewer than our Preferred and Complete solutions.

*Removal from precertification is not a guarantee of payment. Codes may be subject to code editing, benefit plan exclusions and post-service review for coverage.

Code

Code Description

Revenue Radiology-Therapeutic and/or Chemotherapy AdministrationCode 0333 Radiation Therapy

Revenue Code 0870 Revenue Code 0871

Revenue Code 0872

Cell/Gene Therapy - General Classification

Cell/Gene Therapy - Cell Collection Cell/Gene Therapy - Specialized Biologic Processing And Storage - Prior To Transport

Addition/Removal

Precertification delegated to eviCore healthcare National

Radiation Therapy Program; Added

02/27/2016

Added 04/01/2019

Added 04/01/2019

Added 04/01/2019

Complete/PHS+/ Preferred

X

X X X

Basic Standard

X

X X X

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

1

Code Revenue Code 0873 Revenue Code 0874 Revenue Code 0875 Revenue Code 0890 Revenue Code 0891 Revenue Code 0892 Revenue Code 0905 Revenue Code 0906 Revenue Code 0907 Revenue Code 0912 Revenue Code 0913

0007M

0014M

0018M

0058T*

Code Description

Cell/Gene Therapy - Storage And Processing After Receipt Of Cells From Manufacturer

Cell/Gene Therapy - Infusion Of Modified Cells

Cell/Gene Therapy - Injection Of Modified Cells

Pharmacy - Extension Of 025X And 063X - Reserved (Use 0250 For General Classification) Pharmacy - Extension Of 025X And 063X - Special Processed Drugs ? FDA Approved Cell Therapy

Special Processed Drugs - FDA Approved Gene Therapy

Intensive outpatient services-psychiatric

Intensive outpatient services-chemical dependency

Community behavioral health program (day treatment)

Partial hospitalization-less intensive

Partial hospitalization- intensive

Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index

Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+Tcytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score Cryopreservation; reproductive tissue, ovarian

Addition/Removal Added 04/01/2019 Added 04/01/2019 Added 04/01/2019 Added 04/01/2019 Added 04/01/2019 Added 04/01/2020 Added 08/27/2015 Added 08/27/2015 Added 08/27/2015 Added 08/27/2015 Added 08/27/2015

Added 07/01/2014

Added 04/01/2020

Added 10/01/2021 Added 07/01/2011 Removed 11/07/2020

Complete/PHS+/ Preferred

X X X X X X X X X X X

X

X

X

X

Basic Standard

X X X X X X

X X

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

2

Code 0071T 0072T

0075T

0076T 0085T* 0098T 0101T* 0102T* 0111T* 0163T 0165T*

Code Description

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue

Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel

Addition/Removal

Complete/PHS+/ Preferred

X

Basic Standard

X

X

X

Added 10/25/2019

X

Transcatheter placement of extracranial vertebral or intrathoracic

carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; each additional vessel (List

Added 10/25/2019

X

separately in addition to code for primary procedure)

Breath test for heart transplant rejection

Removed 11/07/2020

X

X

Revision of total disc arthroplasty, anterior approach; each

additional interspace (List separately in addition to code for

X

primary procedure)

Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy

Removed 11/07/2020

X

X

Extracorporeal shock wave, high energy, performed by a

physician, requiring anesthesia other than local, involving lateral

Removed 11/07/2020

X

X

humeral epicondyle

Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes

Removed 11/07/2020

X

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace

X

X

Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace

Removed 11/07/2020

X

X

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

3

Code

0174T*

0175T* 0191T 0198T* 0200T 0201T

0202T* 0207T* 0208T* 0209T* 0210T*

Code Description

Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation

Addition/Removal

Complete/PHS+/ Preferred

Removed 11/07/2020

X

Basic Standard

X

Computer aided detection (CAD) (computer algorithm analysis of

digital image data for lesion detection) with further physician

review for interpretation and report, with or without digitization of

Removed 11/07/2020

X

X

film radiographic images, chest radiograph(s), performed remote

from primary interpretation

Insertion aqueous drainage device internal approach

X

Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report

Removed 11/07/2020

X

X

Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), one or more needles

Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), two or more needles

X

X

X

X

Posterior vertebral joint(s) arthroplasty (e.g. facet joint(s)

replacement) inc facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone

Removed 11/07/2020

X

X

cement, inc fluoroscopy, single level, lumbar spine

Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral

Removed 11/07/2020

X

X

Pure tone audiometry (threshold), automated; air only

Removed 11/07/2020

X

X

Pure tone audiometry (threshold), automated; air and bone

Removed 11/07/2020

X

X

Speech audiometry threshold, automated

Removed 11/07/2020

X

X

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

4

Code 0211T* 0212T* 0213T 0214T

0215T

0216T 0217T

0218T

Code Description

Speech audiometry threshold, automated; with speech recognition

Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Addition/Removal

Removed 11/07/2020

Removed 11/07/2020

All markets are effective with eviCore healthcare

except for Hawaii, Puerto Rico and Guam All markets are effective with eviCore healthcare

except for Hawaii, Puerto Rico and Guam

All markets are effective with eviCore healthcare

except for Hawaii, Puerto Rico and Guam

Complete/PHS+/ Preferred

X X X

X

X

All markets are effective

Injection(s), diagnostic or therapeutic agent, paravertebral facet

with eviCore healthcare

(zygapophyseal) joint (or nerves innervating that joint) with

except for Hawaii,

X

ultrasound guidance, lumbar or sacral; single level

Puerto Rico and Guam

All markets are effective

Injection(s), diagnostic or therapeutic agent, paravertebral facet

with eviCore healthcare

(zygapophyseal) joint (or nerves innervating that joint) with

except for Hawaii,

X

ultrasound guidance, lumbar or sacral; second level (List

Puerto Rico and Guam

separately in addition to code for primary procedure)

Basic Standard

X

X

Injection(s), diagnostic or therapeutic agent, paravertebral facet All markets are effective

(zygapophyseal) joint (or nerves innervating that joint) with

with eviCore healthcare

X

ultrasound guidance, lumbar or sacral; third and any additional

except for Hawaii,

level(s) (List separately in addition to code for primary procedure) Puerto Rico and Guam

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

5

Code 0219T 0220T* 0221T 0222T 0228T 0229T 0230T

Code Description

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical

Addition/Removal

Complete/PHS+/ Preferred

X

Placement of a posterior intrafacet implant(s), unilateral or

bilateral, including imaging and placement of bone graft(s) or

Removed 11/07/2020

X

synthetic device(s), single level; thoracic

Placement of a posterior intrafacet implant(s), unilateral or

bilateral, including imaging and placement of bone graft(s) or

X

synthetic device(s), single level; lumbar

Placement of a posterior intrafacet implant(s), unilateral or

bilateral, including imaging and placement of bone graft(s) or

synthetic device(s), single level; each additional vertebral

X

segment (List separately in addition to code for primary

procedure)

Removed 01/01/2021

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

All markets were effective with eviCore healthcare except for Hawaii, Puerto Rico and

X

Guam

Removed 01/01/2021

Injection(s), anesthetic agent and/or steroid, transforaminal

All markets were

epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary

effective with eviCore healthcare except for

X

procedure)

Hawaii, Puerto Rico and

Guam

Removed 01/01/2021

All markets were

Injection(s), anesthetic agent and/or steroid, transforaminal

effective with eviCore

X

epidural, with ultrasound guidance, lumbar or sacral; single level

healthcare except for

Hawaii, Puerto Rico and

Guam

Basic Standard

X

X

X

X

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

6

Code 0231T 0232T 0253T* 0263T 0264T*

0265T*

0266T*

Code Description

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed

Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space

Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest

Addition/Removal

Removed 01/01/2021 All markets were

effective with eviCore healthcare except for Hawaii, Puerto Rico and

Guam

Complete/PHS+/ Preferred

X

X

Removed 11/07/2020

X

Added 07/01/2011

X

Basic Standard

X X X

Intramuscular autologous bone marrow cell therapy, with

preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest. Complete

Added 07/01/2011 Removed 11/07/2020

X

X

procedure excluding bone marrow harvest

Intramuscular autologous bone marrow cell therapy, with

preparation of harvested cells, multiple injections, one leg,

including ultrasound guidance, if performed; complete procedure

Added 07/01/2011

X

X

including unilateral or bilateral bone marrow harvest. Unilateral or Removed 11/07/2020

bilateral bone marrow harvest only for intramuscular autologous

bone marrow cell therapy

Implantation or replacement of carotid sinus baroreflex activation

device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation,

Added 07/01/2011 Removed 11/07/2020

X

X

programming, and repositioning, when performed)

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

7

Code 0267T* 0268T* 0269T* 0270T* 0271T*

Code Description

Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) Lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)

Addition/Removal

Complete/PHS+/ Preferred

Added 07/01/2011

X

Removed 11/07/2020

Basic Standard

X

Implantation or replacement of carotid sinus baroreflex activation

device; total system (includes generator placement, unilateral or

bilateral lead placement, intra-operative interrogation,

Added 07/01/2011

X

X

programming, and repositioning, when performed) Pulse

Removed 11/07/2020

generator only (includes intra-operative interrogation,

programming, and repositioning, when performed)

Revision or removal of carotid sinus baroreflex activation device;

total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and

Added 07/01/2011 Removed 11/07/2020

X

X

repositioning, when performed)

Revision or removal of carotid sinus baroreflex activation device;

total system (includes generator placement, unilateral or bilateral

lead placement, intra-operative interrogation, programming, and repositioning, when performed) lead only, unilateral (includes

Added 07/01/2011 Removed 11/07/2020

X

X

intra-operative interrogation, programming, and repositioning,

when performed)

Revision or removal of carotid sinus baroreflex activation device;

total system (includes generator placement, unilateral or bilateral

lead placement, intra-operative interrogation, programming, and repositioning, when performed) pulse generator only (includes

Added 07/01/2011 Removed 11/07/2020

X

X

intra-operative interrogation, programming, and repositioning,

when performed)

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express

Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ? 2022 Cigna. Some content provided under license.

8

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download