The following tables show the up-coming code changes to the EmblemHealth Preauthorization List July 1, Sept. 1, and Nov. 1, 2022.
As part of our annual review of advanced radiology preauthorization requirements in collaboration with our partner, eviCore, we have determined that the following CPT Codes will be added to the EmblemHealth Preauthorization List starting July 1, 2022.
| CPT Code/HCPCS Code | CPT Code Description |
|---|---|
74263 |
Computed tomographic (CT) colonography, screening, including image postprocessing |
78429 |
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, with concurrently acquired computed tomography transmission scan |
78430 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan |
78431 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan |
78432 |
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (e.g., myocardial viability) |
78433 |
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); dual radiotracer (e.g., myocardial viability), with concurrently acquired computed tomography transmission scan |
78434 |
Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) |
78830 |
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (e.g., head, neck, chest, pelvis), single-day imaging |
78831 |
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single-day imaging, or single-area imaging over 2 or more days |
78832 |
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single-day imaging, or single-area imaging over 2 or more days |
93356 |
Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging) |
93452 |
Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed |
93453 |
Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed |
93454 |
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation |
93455 |
Catheter placement in coronary artery(s) for coronary angiography including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography |
93456 |
Catheter placement in coronary artery(s) for coronary angiography including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization |
93457 |
Catheter placement in coronary artery(s) for coronary angiography including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization |
93460 |
Catheter placement in coronary artery(s) for coronary angiography including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed |
93461 |
Catheter placement in coronary artery(s) for coronary angiography including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography |
0331T |
Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment |
0332T |
Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT |
0439T |
Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure) |
0609T |
Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (i.e., lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs |
0610T |
Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis |
0611T |
Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs |
0612T |
Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report |
0633T |
Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material |
0634T |
Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) |
0635T |
Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) |
0636T |
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) |
0637T |
Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) |
0638T |
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) |
C8931 |
Magnetic resonance angiography with contrast, spinal canal and contents |
C8932 |
Magnetic resonance angiography without contrast, spinal canal and contents |
C8933 |
Magnetic resonance angiography without contrast followed by contrast, spinal canal and contents |
C8934 |
Magnetic resonance angiography with contrast, upper extremity |
C8935 |
Magnetic resonance angiography without contrast, upper extremity |
C8936 |
Magnetic resonance angiography without contrast followed by contrast, upper extremity |
C9762 |
Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging |
C9763 |
Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging |
G0219 |
PET imaging whole body; melanoma for noncovered indications |
G0235 |
PET imaging, any site, not otherwise specified |
G0252 |
PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) |
G0458 |
Low dose rate (LDR) prostate brachytherapy services, composite rate |
S8037 |
Magnetic resonance cholangiopancreatography (MRCP) |
S8042 |
Magnetic resonance imaging (MRI), low-field |
S8085 |
Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (nondedicated PET scan) |
In addition, the following CPT Codes will be removed from the preauthorization list:
| CPT Code/HCPCS Code | CPT Code Description |
|---|---|
76873 |
Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) |
76948 |
Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation |
93325 |
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) |
93462 |
Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) |
A6261 |
Wound filler, gel/paste, per fl oz, not otherwise specified |
A6262 |
Wound filler, dry form, per g, not otherwise specified |
A6549 |
Gradient compression stocking/sleeve, not otherwise specified |
E0159 |
Brake attachment for wheeled walker, replacement, each |
E0189 |
Lambswool sheepskin pad, any size |
E0210 |
Electric heat pad, standard |
E0940 |
Trapeze bar, freestanding, complete with grab bar |
E0955 |
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each |
E1011 |
Modification to pediatric-size wheelchair, width adjustment package (not to be dispensed with initial chair) |
E1028 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory |
E2207 |
Wheelchair accessory, crutch and cane holder, each |
E2220 |
Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each |
E2221 |
Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each |
E2222 |
Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each |
E2291 |
Back, planar, for pediatric-size wheelchair including fixed attaching hardware |
E2292 |
Seat, planar, for pediatric-size wheelchair including fixed attaching hardware |
E2293 |
Back, contoured, for pediatric-size wheelchair including fixed attaching hardware |
E2294 |
Seat, contoured, for pediatric-size wheelchair including fixed attaching hardware |
K0015 |
Detachable, nonadjustable height armrest, each |
K0019 |
Arm pad, replacement only, each |
K0020 |
Fixed, adjustable height armrest, pair |
K0040 |
Adjustable angle footplate, each |
K0042 |
Standard size footplate, replacement only, each |
K0043 |
Footrest, lower extension tube, replacement only, each |
K0044 |
Footrest, upper hanger bracket, replacement only, each |
K0045 |
Footrest, complete assembly, replacement only, each |
K0046 |
Elevating leg rest, lower extension tube, replacement only, each |
K0047 |
Elevating leg rest, upper hanger bracket, replacement only, each |
K0050 |
Ratchet assembly, replacement only |
K0070 |
Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each |
K0077 |
Front caster assembly, complete, with solid tire, replacement only, each |
K0098 |
Drive belt for power wheelchair, replacement only |
K0601 |
Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each |
K0602 |
Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each |
K0603 |
Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each |
K0604 |
Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each |
K0605 |
Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each |
K0733 |
Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) |
L0980 |
Peroneal straps, prefabricated, off-the-shelf, pair |
L0982 |
Stocking supporter grips, prefabricated, off-the-shelf, set of four (4) |
L3201 |
Orthopedic shoe, Oxford with supinator or pronator, infant |
L3204 |
Orthopedic shoe, hightop with supinator or pronator, infant |
L3206 |
Orthopedic shoe, hightop with supinator or pronator, child |
L6611 |
Addition to upper extremity prosthesis, external powered, additional switch, any type |
L6621 |
Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external-powered terminal device |
L6629 |
Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal |
L6632 |
Upper extremity addition, latex suspension sleeve, each |
L6677 |
Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow |
L6680 |
Upper extremity addition, test socket, wrist disarticulation or below elbow |
L6682 |
Upper extremity addition, test socket, elbow disarticulation or above elbow |
L6686 |
Upper extremity addition, suction socket |
L6687 |
Upper extremity addition, frame type socket, below elbow or wrist disarticulation |
L6688 |
Upper extremity addition, frame type socket, above elbow or elbow disarticulation |
L6694 |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism |
L6695 |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
L6696 |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695) |
L6697 |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695) |
L6698 |
Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert |
L6883 |
Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power |
L6884 |
Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power |
L6890 |
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment |
L7400 |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultra-light material (titanium, carbon fiber or equal) |
L7401 |
Addition to upper extremity prosthesis, above elbow disarticulation, ultra-light material (titanium, carbon fiber or equal) |
L7403 |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material |
L7510 |
Repair of prosthetic device, repair or replace minor parts |
L7520 |
Repair prosthetic device, labor component, per 15 minutes |
L7600 |
Prosthetic donning sleeve, any material, each |
L8002 |
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type |
L8049 |
Repair or modification of maxillofacial prosthesis, labor component, 15-minute increments, provided by a nonphysician |
L8417 |
Prosthetic sheath/sock, including a gel cushion layer, below knee (BK) or above knee (AK), each |
L8465 |
Prosthetic shrinker, upper limb, each |
S1040 |
Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
As part of our annual review of chiropractic services preauthorization requirements in collaboration with our partner, Palladian, we have determined that the following CPT Code will be added to the EmblemHealth Preauthorization List starting September 1, 2022.
| CPT Code/HCPCS Code | CPT Code Description |
|---|---|
97537 |
Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes |
As part of our continued review of durable medical equipment preauthorization requirements in collaboration with our partner, eviCore, we have determined that the following CPT Codes will be added to the EmblemHealth Preauthorization List starting September 1, 2022.
| CPT Code/HCPCS Code | CPT Code Description |
|---|---|
E0170 |
Commode chair with integrated seat lift mechanism, electric, any type |
E0172 |
Seat lift mechanism placed over or on top of toilet, any type |
E0231 |
Noncontact wound-warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover |
E0232 |
Warming card for use with the noncontact wound-warming device and noncontact wound-warming wound cover |
E0265 |
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress |
E0266 |
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress |
E0296 |
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress |
E0297 |
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress |
E0350 |
Control unit for electronic bowel irrigation/evacuation system |
E0446 |
Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories |
E0447 |
Portable oxygen contents, liquid, 1-month’s supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (LPM) |
E0457 |
Chest shell (cuirass) |
E0467 |
Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions |
E0485 |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment |
E0500 |
IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source |
E0560 |
Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery |
E0575 |
Nebulizer, ultrasonic, large volume |
E0676 |
Intermittent limb compression device (includes all accessories), not otherwise specified |
E0694 |
Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection |
E0731 |
Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient’s skin by layers of fabric) |
E0961 |
Manual wheelchair accessory, wheel lock brake extension (handle), each |
E0983 |
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control |
E0984 |
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control |
E0985 |
Wheelchair accessory, seat lift mechanism |
E1017 |
Heavy-duty shock absorber for heavy-duty or extra heavy-duty manual wheelchair, each |
E1018 |
Heavy-duty shock absorber for heavy-duty or extra heavy-duty power wheelchair, each |
E1035 |
Multi-positional patient transfer system, with integrated seat, operated by caregiver, patient weight capacity up to and including 300 lbs |
E1050 |
Fully reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1060 |
Fully reclining wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests |
E1070 |
Fully reclining wheelchair, detachable arms (desk or full-length), swing-away detachable footrest |
E1083 |
Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating leg rest |
E1084 |
Hemi-wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests |
E1085 |
Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests |
E1086 |
Hemi-wheelchair, detachable arms (desk or full-length), swing-away detachable footrests |
E1087 |
High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1088 |
High strength lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests |
E1089 |
High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest |
E1090 |
High-strength lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable footrests |
E1092 |
Wide heavy-duty wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests |
E1093 |
Wide heavy-duty wheelchair, detachable arms (desk or full-length arms), swing-away detachable footrests |
E1100 |
Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1110 |
Semi-reclining wheelchair, detachable arms (desk or full-length) elevating leg rest |
E1130 |
Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests |
E1140 |
Wheelchair, detachable arms (desk or full-length), swing-away detachable footrests |
E1150 |
Wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests |
E1160 |
Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1195 |
Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1220 |
Wheelchair; specially sized or constructed (indicate brand name, model number, if any), and justification |
E1221 |
Wheelchair with fixed arm, footrests |
E1222 |
Wheelchair with fixed arm, elevating leg rests |
E1223 |
Wheelchair with detachable arms, footrests |
E1224 |
Wheelchair with detachable arms, elevating leg rests |
E1225 |
Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each |
E1227 |
Special height arms for wheelchair |
E1229 |
Wheelchair, pediatric size, not otherwise specified |
E1230 |
Power-operated vehicle (three- or four-wheel nonhighway), specify brand name and model number |
E1239 |
Power wheelchair, pediatric size, not otherwise specified |
E1240 |
Lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable, elevating leg rest |
E1250 |
Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest |
E1260 |
Lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable footrest |
E1270 |
Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests |
E1280 |
Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests |
E1285 |
Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest |
E1290 |
Heavy-duty wheelchair, detachable arms (desk or full-length), swing-away detachable footrest |
E1295 |
Heavy-duty wheelchair, fixed full-length arms, elevating leg rest |
E1296 |
Special wheelchair seat height from floor |
E1298 |
Special wheelchair seat depth and/or width, by construction |
E1300 |
Whirlpool, portable (overtub type) |
E1310 |
Whirlpool, nonportable (built-in type) |
E1700 |
Jaw motion rehabilitation system |
E2228 |
Manual wheelchair accessory, wheel braking system and lock, complete, each |
E2340 |
Power wheelchair accessory, nonstandard seat frame width, 20-23 in |
E2341 |
Power wheelchair accessory, nonstandard seat frame width, 24-27 in |
E2342 |
Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in |
E2343 |
Power wheelchair accessory, nonstandard seat frame depth, 22-25 in |
E2378 |
Power wheelchair component, actuator, replacement only |
E2605 |
Positioning wheelchair seat cushion, width less than 22 in, any depth |
E2606 |
Positioning wheelchair seat cushion, width 22 in or greater, any depth |
E2607 |
Skin protection and positioning wheelchair seat cushion, width less than 22 in, any depth |
E2608 |
Skin protection and positioning wheelchair seat cushion, width 22 in or greater, any depth |
E2609 |
Custom-fabricated wheelchair seat cushion, any size |
E2610 |
Wheelchair seat cushion, powered |
K0669 |
Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC |
K0830 |
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0831 |
Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds |
K0900 |
Customized durable medical equipment, other than wheelchair |
L0456 |
Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
L0622 |
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated |
L2050 |
Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated |
L2060 |
Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated |
L2080 |
Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated |
L2090 |
Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated |
L2188 |
Addition to lower extremity fracture orthosis, quadrilateral brim |
L2250 |
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment |
L2280 |
Addition to lower extremity, molded inner boot |
L2300 |
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable |
L2330 |
Addition to lower extremity, lacer molded to patient model, for custom-fabricated orthosis only |
L2340 |
Addition to lower extremity, pretibial shell, molded to patient model |
L2350 |
Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model (used for PTB, AFO orthoses) |
L2500 |
Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring |
L2510 |
Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model |
L2520 |
Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted |
L2525 |
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model |
L2526 |
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted |
L2540 |
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model |
L2570 |
Addition to lower extremity, pelvic control, hip joint, Clevis type two-position joint, each |
L2580 |
Addition to lower extremity, pelvic control, pelvic sling |
L2627 |
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables |
L2628 |
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables |
L3671 |
Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3760 |
Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
L3761 |
Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf |
L3806 |
Wrist-hand-finger orthosis (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment |
L3808 |
Wrist-hand-finger orthosis (WHFO), rigid without joints, may include soft interface material, straps, custom fabricated, includes fitting and adjustment |
L3891 |
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom-fabricated orthotics only, each |
L3904 |
Wrist-hand-finger orthosis (WHFO), external powered, electric, custom fabricated |
L3905 |
Wrist-hand orthosis (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3915 |
Wrist-hand orthosis (WHO), includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
L3921 |
Hand-finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3960 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning, airplane design, prefabricated, includes fitting and adjustment |
L3961 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3962 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning, Erb’s palsy design, prefabricated, includes fitting and adjustment |
L3967 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3971 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3973 |
Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3976 |
Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3977 |
Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3978 |
Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3980 |
Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment |
L4360 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
L5673 |
Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism |
L5679 |
Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
L5683 |
Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679) |
L5990 |
Addition to lower-extremity prosthesis, user-adjustable heel height |
L6965 |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Ottobock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device |
L6975 |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Ottobock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device |
L7700 |
Gasket or seal, for use with prosthetic socket insert, any type, each |
L8039 |
Breast prosthesis, not otherwise specified |
L8499 |
Unlisted procedure for miscellaneous prosthetic services |
L8500 |
Artificial larynx, any type |
L8701 |
Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
L8702 |
Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
The following CPT Codes will be added to the EmblemHealth Preauthorization List starting November 1, 2022.
| CPT Code/HCPCS Code | CPT Code Description |
|---|---|
64628 |
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral |
64629 |
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) |
