Master Precertification List - Cigna

1 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. 2020 Cigna . Some content provided under license. 1 0f Master Precertification LIST For Health Care Providers Effective January 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.

2 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 Addition/Removal Complete/PHS+/Preferred Basic Standard Revenue Code 0333 Radiology-Therapeutic and/or Chemotherapy Administration-Radiation Therapy Precertification delegated to eviCore healthcare National Radiation Therapy Program; Added 02/27/2016 X X Revenue Code 0870 Cell/Gene Therapy - General Classification Added 04/01/2019 X X Revenue Code 0871 Cell/Gene Therapy - Cell Collection Added 04/01/2019 X X Revenue Code 0872 Cell/Gene Therapy - Specialized Biologic Processing And Storage - Prior To Transport Added 04/01/2019 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.

3 The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2020 Cigna . Some content provided under license. 2 Code Code Description Addition/Removal Complete/PHS+/Preferred Basic Standard Revenue Code 0873 Cell/Gene Therapy - Storage And Processing After Receipt Of Cells From Manufacturer Added 04/01/2019 X X Revenue Code 0874 Cell/Gene Therapy - Infusion Of Modified Cells Added 04/01/2019 X X Revenue Code 0875 Cell/Gene Therapy - Injection Of Modified Cells Added 04/01/2019 X X Revenue Code 0890 Pharmacy - Extension Of 025X And 063X - Reserved (Use 0250 For General Classification) Added 04/01/2019 X X Revenue Code 0891 Pharmacy - Extension Of 025X And 063X - Special Processed Drugs FDA Approved Cell Therapy Added 04/01/2019 X X Revenue Code 0892 Special Processed Drugs - FDA Approved Gene Therapy Added 04/01/2020 X X Revenue Code 0905 Intensive outpatient services-psychiatric Added 08/27/2015 X Revenue Code 0906 Intensive outpatient services-chemical dependency Added 08/27/2015 X Revenue Code 0907 Community behavioral health program (day treatment) Added 08/27/2015 X Revenue Code 0912 Partial hospitalization-less intensive Added 08/27/2015 X Revenue Code 0913 Partial hospitalization- intensive Added 08/27/2015 X 0007M Oncology (gastrointestinal neuroendocrine tumors)

4 , real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index Added 07/01/2014 X 0014M 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 Added 04/01/2020 X 0018M Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score Added 10/01/2021 X X 0058T* Cryopreservation; reproductive tissue, ovarian Added 07/01/2011 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.

5 The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2020 Cigna . Some content provided under license. 3 Code Code Description Addition/Removal Complete/PHS+/Preferred Basic Standard 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue X X 0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue X X 0075T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel Added 10/25/2019 X 0076T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; each additional vessel (List separately in addition to code for primary procedure) Added 10/25/2019 X 0085T* Breath test for heart transplant rejection Removed 11/07/2020 X X 0098T Revision of total disc arthroplasty, anterior approach.

6 Each additional interspace (List separately in addition to code for primary procedure) X 0101T* Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy Removed 11/07/2020 X X 0102T* Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle Removed 11/07/2020 X X 0111T* Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes Removed 11/07/2020 X 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace X X 0165T* 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.

7 The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2020 Cigna . Some content provided under license. 4 Code Code Description Addition/Removal Complete/PHS+/Preferred Basic Standard 0174T* 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 Removed 11/07/2020 X X 0175T* 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 remote from primary interpretation Removed 11/07/2020 X X 0191T Insertion aqueous drainage device internal approach X 0198T* Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report Removed 11/07/2020 X X 0200T Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), one or more needles X X 0201T Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), two or more needles X X 0202T* Posterior vertebral joint(s) arthroplasty ( facet joint(s) replacement)

8 Inc facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, inc fluoroscopy, single level, lumbar spine Removed 11/07/2020 X X 0207T* Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral Removed 11/07/2020 X X 0208T* Pure tone audiometry (threshold), automated; air only Removed 11/07/2020 X X 0209T* Pure tone audiometry (threshold), automated; air and bone Removed 11/07/2020 X X 0210T* 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. 2020 Cigna . Some content provided under license. 5 Code Code Description Addition/Removal Complete/PHS+/Preferred Basic Standard 0211T* Speech audiometry threshold, automated; with speech recognition Removed 11/07/2020 X X 0212T* Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated Removed 11/07/2020 X X 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam X 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic.

9 Second level (List separately in addition to code for primary procedure) All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam X 0215T 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) All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam X 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam X 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam X 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral.

10 Third and any additional level(s) (List separately in addition to code for primary procedure) All markets are effective with eviCore healthcare except for Hawaii, Puerto Rico and Guam 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. 2020 Cigna . Some content provided under license. 6 Code Code Description Addition/Removal Complete/PHS+/Preferred Basic Standard 0219T 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 X X 0220T* Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic Removed 11/07/2020 X X 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar X X 0222T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level.