Cardiology Notification and Prior Authorization Program ...

1 UnitedHeathcare | Prior Authorization UnitedHealthcare Cardiology Notification and Prior Authorization Program Electrophysiology implant CPT code classification table The following chart contains the CPT codes that require Notification or Prior Authorization as part of the UnitedHealthcare Cardiology Notification / Prior Authorization Program . Notification and Prior Authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific Notification or Prior Authorization requirements by member, please call 1-866-889-8054. Includes Includes Includes lead removal CPT code CPT Description generator Device type plancement of existing placement device Insertion of new or replacement of permanent pacemaker with 33206 Yes Yes No pacemaker transvenous electrode(s); atrial Insertion of new or replacement of permanent pacemaker with 33207 Yes Yes No pacemaker transvenous electrode(s); ventricular Insertion of new or replacement of permanent pacemaker with pacemaker /.

2 33208 Yes Yes No transvenous electrode(s); atrial and ventricular CRT. 33212 Insertion of pacemaker pulse generator only; with existing single lead Yes No No pacemaker 33213 Insertion of pacemaker pulse generator only; with existing dual leads Yes No No pacemaker Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed 33214 Yes Yes Yes pacemaker pulse generator, testing of existing lead, insertion of new lead, insertion of new generator). 33221 Insertion of pacemaker pulse generator only; with existing multiple leads Yes No No CRT. Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable 33224 Yes Yes Yes CRT.

3 Defibrillator pulse generator (including revision of pocket, removal, insertion and/or replacement of existing generator). Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse 33225 Yes Yes No CRT. generator ( , for upgrade to dual chamber system) (list separately in addition to code for primary procedure). Removal of permanent pacemaker pulse generator with replacement of 33227 Yes No Yes pacemaker pacemaker pulse generator; single lead system Removal of permanent pacemaker pulse generator with replacement of 33228 Yes No Yes pacemaker pacemaker pulse generator; dual lead system Removal of permanent pacemaker pulse generator with replacement of 33229 Yes No Yes CRT.

4 pacemaker pulse generator; multiple lead system Insertion of implantable defibrillator pulse generator only; with existing 33230 Yes No No ICD. dual leads Insertion of implantable defibrillator pulse generator only; with existing 33231 Yes No No CRT. multiple leads Insertion of implantable defibrillator pulse generator only; with existing 33240 Yes No No ICD. single lead Insertion or replacement of permanent implantable defibrillator system, 33249 Yes Yes No ICD/CRT. with transvenous lead(s); single or dual chamber PCA-1-21-01993--VC-Web_06282021. Includes Includes Includes lead removal CPT code CPT Description generator Device type plancement of existing placement device Removal of implantable defibrillator pulse generator with replacement of 33262 Yes No Yes ICD.

5 Implantable defibrillator pulse generator; single lead system Removal of implantable defibrillator pulse generator with replacement of 33263 Yes No Yes ICD. implantable defibrillator pulse generator; dual lead system Removal of implantable defibrillator pulse generator with replacement of 33264 Yes No Yes ICD. implantable defibrillator pulse generator; multiple lead system Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation 33270 threshold evaluation, induction of arrhythmia, evaluation of sensing for Yes No Yes ICD. arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Insertion or replacement of implantable cardioverter defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold 0517T Yes No No ICD.)

6 Evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed Removal and replacement of substernal implantable defibrillator 0614T Yes No Yes ICD. pulse generator Diagnostic catheterization CPT code classification table The following chart contains the CPT codes that require Notification or Prior Authorization as part of the UnitedHealthcare Cardiology Notification / Prior Authorization Program . Notification and Prior Authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific Notification or Prior Authorization requirements by member, please 1-866-889-8054.

7 CPT code CPT Description Left heart catheterization, including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, 93452. when performed Combined right and left heart catheterization, including intraprocedural injection(s) for left ventriculography, imaging supervision and 93453. interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93454. supervision and interpretation Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93455 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 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93456.

8 Supervision and interpretation; with right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93457 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 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93458. supervision and interpretation; with left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93459 supervision and interpretation.

9 With 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 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93460 supervision and interpretation; with right and left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 93461 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 PCA-1-21-01993--VC-Web_06282021.

10 Echocardiography & stress echocardiography CPT code classification table The following chart contains the CPT codes that require Prior Authorization as part of the UnitedHealthcare Cardiology Prior Authorization Program . Prior Authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific Notification or Prior Authorization requirements by member, please call 1-866-889-8054. CPT code CPT Description 93303 Transthoracic echocardiography for congenital cardiac anomalies 93304 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with 93306.