Code List Individual PBC - Premera Blue Cross

1 Individual Plans Only View Non- Individual Plan code list code List (CODES REVIEWED ARE SUBJECT TO CHANGE). We're currently working with local government regarding the COVID-19 virus and its impact on our area. View COVID-19 FAQ. How do I ensure accurate coverage information? Use the code list, consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply. Specific codes can be found here on the code list within the following pages.

2 What is the code list? This is a listing the codes found in the Company's medical policies. The code list provides the following information: The code and type of code (CPT or HCPCS) with a description The type of review required (eg, prior authorization or retrospective review) or if the service potentially may be denied If the code must meet medical necessity criteria to be approved, or if it is considered investigative, cosmetic, specialized durable medical equipment, or is an unlisted (non-specific) code If specific medical records are required with the request What are the types of review done for a service?

3 There are two types of reviews conducted to a service provided: prior authorization and retrospective review. Each type of review determines if the service is medically necessary for the member's admission, stay, other service, or course of treatment, including outpatient procedures and services. Services that are not medically necessary are not covered, whether the review is done as a prior authorization or post service. Prior authorization: Prior authorization/certification is required by the member's contract.

4 If a provider performs a service or procedure without prior authorization, depending on the member's benefit plan, the charges/claim will either be denied or a penalty will be applied. Post service or retrospective review: This refers to any review conducted after services have been provided, including outpatient procedures and services. Services requiring prior authorization are listed below. This list is subject to change. Please refer to the member's contract for specific coverage details. An Independent Licensee of the blue Cross blue Shield Association.

5 Page i of vii 050237 (01-07-2022). 2013-2022. Premera . All Rights Reserved. Behavioral Health Durable Medical Equipment (DME) and Prosthetic Devices Applied behavioral analysis (ABA) Prior authorization is required for purchases or rentals over Cognitive testing $750, regardless of place of service. Rentals extending beyond Electroconvulsive therapy three months require review for medical necessity. Inpatient admission (mental health and substance abuse disorder) DME items include, and are not limited to.

6 Intensive outpatient hospitalization (mental health and Bone growth stimulators electronic and ultrasonic substance abuse disorder) Chest compression vests and devices Neurobehavioral status exam Cochlear devices Neuropsychological testing Compression units Partial hospitalization programs (mental health and Continuous glucose monitors substance abuse disorder) Custom-made knee braces Psychological testing DME corrective appliances Residential treatment programs (mental health and Electrical stimulation devices includes bone growth substance abuse disorder) stimulators Electronic, mechanical or microprocessor-controlled Dental Services artificial limb or joint Anesthesia for dental services and related facility charges Equipment and supplies to treat obstructive sleep apnea.

7 Medically necessary orthodontia (medically necessary CPAP, BiPAP and APAP machines and related supplies braces for the teeth) External insulin pumps Orthognathic surgery (jaw enlargement or reduction) Hearing aids Pediatric orthodontia, non-routine (non-routine braces for Hospital beds and accessories children) reviewed by Dental staff o No prior authorization needed for rental of standard Sleep apnea intraoral appliances (devices worn in the beds for hospital to home transitions for less than 3. mouth to treat sleep apnea) months Temporomandibular (TMJ) treatments (MRIs, oral splints, Infusion pumps mouth guards, TMJ surgery) Lymphedema pumps (pumps to reduce swelling).

8 Medical foods Myoelectric upper limb prosthetic (externally powered artificial arm or hand). Negative pressure wound therapy An Independent Licensee of the blue Cross blue Shield Association. Page ii of vii 050237 (01-07-2022). 2013-2022. Premera . All Rights Reserved. Oral devices, appliances, surgical splints and impressions . includes preparation Surgical, Medical, Therapeutic, Diagnostic and Reconstructive Power-operated lifting devices Procedures (inpatient or outpatient). Spinal orthosis Ablation therapy (destruction of abnormal tissue).

9 Standing frames Surgical procedures in an outpatient setting Traction and orthopedic devices Artificial intervertebral disc, any level (artificial disc between Vagal nerve stimulators other than TENS (implanted vertebrae in the spine). devices to stimulate a specific nerve) Bioengineered skin substitutes Wheelchairs, power-operated vehicles, and scooters Blepharoplasty (eyelid surgery). Bone-anchored and implantable hearing aids Home Health Care Breast surgeries selected: implant removal, mastectomy Home Health for gynecomastia (removal of breast tissue in males), Home infusion prophylactic mastectomy (removal of breasts to prevent Pain management/palliative care (some procedures) breast cancer), reduction mammoplasty (breast reduction).

10 Parental nutrition Cardiac devices, including related services for implantation Skilled home health care services if applicable: ventricular assist devices for outpatient (a Skilled hourly nursing care certain kind of device to help the heart pump), implanted and wearable defibrillators (a device to shock the heart into Inpatient Facility Admissions a normal rhythm); closure devices for septal defects (a hole Admission to a skilled nursing facility, a long-term acute in a specific part of the heart); defibrillators, subcutaneous care hospital (LTACH) or a rehabilitation facility implantable; transcatheter aortic valve replacement known Admission to all residential treatment programs as TAVR/TAVI (a specific procedure that replaces the All planned (elective) inpatient hospital care (surgical, non- heart's aortic valve).)