Non-Covered Diagnosis Codes - UHCprovider.com

1 Non-Covered Diagnosis Codes Page 1 of 6 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 01/12/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Medicare Advantage Policy Appendix: Applica ble Code List Non-Covered Diagnosis Codes This list of Codes applies to the Medicare Advantage Policy Guidelines titled: Last Updated: January 12, 2022 Biomarkers in Cardiovascular Risk Assessment Blood Transfusions (NCD ) BRCA1 and BRCA2 Genetic Testing Clinical Diagnostic Laboratory Services Computed Tomography (NCD ) Genetic Testing for Lynch Syndrome Lymphocyte Mitogen Response Assays (NCD ) Magnetic Resonance Imaging (NCD ) Molecular Diagnostic Infectious Disease Testing Molecular Pathology Procedures for Human Leukocyte Antigen (HLA)

2 Typing Molecular Pathology/ Genetic Testing Reported with Unlisted Codes Molecular Pathology/Molecular diagnostics /Genetic Testing Noninvasive Tests of Carotid Function (NCD ) Tier 2 Molecular Pathology Procedures Ultrasound Diagnostic Procedures (NCD ) Applicable Codes The following list(s) of procedure and/or Diagnosis Codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or Non-Covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.

3 The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. Diagnosis Code Description Non-Covered R99 Ill- defined and unknown cause of mortality Encounter for general adult medical examination without abnormal findings Encounter for general adult medical examination with abnormal findings Health examination for newborn under 8 days old Health examination for newborn 8 to 28 days old Encounter for routine child health examination with abnormal findings Encounter for routine child health examination without abnormal findings Encounter for examination of potential donor of organ and tissue

4 Encounter for examination for period of delayed growth in childhood without abnormal findings Encounter for examination for period of delayed growth in childhood with abnormal findings Encounter for other general examination Encounter for examination for admission to educational institution Encounter for pre-employment examination Encounter for examination for admission to residential institution Encounter for examination for recruitment to armed forces Encounter for examination for driving license Encounter for examination for participation in sport Non-Covered Diagnosis Codes Page 2 of 6 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 01/12/2022 Proprietary Information of UnitedHealthcare.

5 Copyright 2022 United HealthCare Services, Inc. Diagnosis Code Description Non-Covered Encounter for examination for insurance purposes Encounter for disability determination Encounter for issue of other medical certificate Encounter for paternity testing Encounter for adoption services Encounter for blood-alcohol and blood-drug test Encounter for other administrative examinations Encounter for administrative examinations, unspecified Encounter for general psychiatric examination, requested by authority Encounter for examination and observation of victim following forced sexual exploitation Encounter for examination and observation of victim following forced labor exploitation Encounter for examination and observation for other specified reasons Encounter for examination and observation for unspecified reason Encounter for screening for intestinal infectious diseases Encounter for screening for respiratory tuberculosis Encounter for screening for other bacterial diseases Encounter for screening for infections with a

6 Predominantly sexual mode of transmission Encounter for screening for human immunodeficiency virus [HIV] Encounter for screening for human papillomavirus (HPV) Encounter for screening for other viral diseases Encounter for screening for other protozoal diseases and helminthiases Encounter for testing for latent tuberculosis infection Encounter for screening for other infectious and parasitic diseases Encounter for screening for infectious and parasitic diseases, unspecified Encounter for screening for malignant neoplasm of stomach Encounter for screening for malignant neoplasm of intestinal tract.

7 Unspecified Encounter for screening for malignant neoplasm of small intestine Encounter for screening for malignant neoplasm of respiratory organs Encounter for screening for malignant neoplasm of bladder Encounter for screening for malignant neoplasm of testis Encounter for screening for malignant neoplasm of vagina Encounter for screening for malignant neoplasm of ovary Encounter for screening for malignant neoplasm of other genitourinary organs Encounter for screening for malignant neoplasm of oral cavity Encounter for screening for malignant neoplasm of nervous system Encounter for screening for malignant neoplasm of skin Encounter for screening for malignant neoplasm of other sites Encounter for screening for malignant neoplasm, site unspecified Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Encounter for screening for nutritional disorder Non-Covered Diagnosis Codes Page 3 of 6 UnitedHealthcare Medicare Advantage Policy Appendix.

8 Applicable Code List Approval 01/12/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. Diagnosis Code Description Non-Covered Encounter for screening for lipoid disorders Encounter for screening for other metabolic disorders Encounter for screening for other suspected endocrine disorder Encounter for screening examination for mental health and behavioral disorders, unspecified Encounter for screening for depression Encounter for screening for maternal depression Encounter for screening examination for other mental health and behavioral disorders Encounter for screening for unspecified developmental delays Encounter for autism screening Encounter for screening for global developmental delays (milestones)

9 Encounter for screening for other developmental delays Encounter for screening for eye and ear disorders Encounter for nonprocreative screening for genetic disease carrier status Encounter for other screening for genetic and chromosomal anomalies Encounter for screening for upper gastrointestinal disorder Encounter for screening for lower gastrointestinal disorder Encounter for screening for other digestive system disorders Encounter for screening for osteoporosis Encounter for screening for other musculoskeletal disorder Encounter for screening for respiratory disorder NEC Encounter for screening for dental disorders Encounter for screening for traumatic brain injury Encounter for screening for other nervous system disorders Encounter for screening for disorder due to exposure to contaminants Encounter for screening for other disorder Encounter for screening.

10 Unspecified Encounter for antenatal screening for chromosomal anomalies Encounter for antenatal screening for raised alphafetoprotein level Encounter for other antenatal screening follow-up Encounter for antenatal screening for malformations Encounter for antenatal screening for fetal growth retardation Encounter for antenatal screening for isoimmunization Encounter for antenatal screening for hydrops fetalis Encounter for antenatal screening for nuchal translucency Encounter for fetal screening for congenital cardiac abnormalities Encounter for antenatal screening for fetal lung maturity Encounter for antenatal screening for Streptococcus B Encounter for antenatal screening for cervical length Encounter for antenatal screening for uncertain dates Encounter for antenatal screening for fetal macrosomia Non-Covered Diagnosis Codes Page 4 of 6 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 01/12/2022 Proprietary Information of U