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Omnibus Codes – Commercial Medical Policy

Omnibus Codes Page 1 of 188 UnitedHealthcare Commercial Medical Policy Effective 04/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Medica l Policy Omnibus Codes Policy Number: 2022T0535LL Effective Date: April 1, 2022 Instructions for Use Table of Contents Page Coverage Summary .. 1 Coverage Rationale/Clinical Evidence .. 12 Policy History/Revision Information .. 187 Instructions for 188 Coverage Summary All CPT/HCPCS Codes /services addressed in this Policy are noted in the table below. Click the code link to be directed to the full coverage rationale and clinical evidence applicable to each of the listed procedures. CPT is a registered trademark of the American Medical Association code Description Conclusion 0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time Proven in certain circumstances 0061U Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and r)

0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed . Unproven . 0408T: Insertion or replacement of permanent cardiac contractility modulation system,

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