Preauthorization Requirement Changes Starting Oct. 15
and Jan. 1, 2024

0745T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (e.g., CT, MRI, or myocardial perfusion scan) and electrical data (e.g., 12-lead ECG data), and identification of areas of avoidance

0746T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan

0747T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia

0865T

Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion identification, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation, and report, obtained without diagnostic MRI examination of the brain during the same session

0866T

Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion detection, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the brain (List separately in addition to code for primary procedure)

76873

Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

93312

TEE 2D; including probe placement, image acquisition, interpretation, and report

93313

Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only

93314

Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation, and report only

93315

Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation, and report

A4239

Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, one-month supply = 1 unit of service

A4341

Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each

A4342

Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each

A4457

Enema tube, with or without adapter, any type, replacement only, each

A4468

An exsufflation belt is a stand-alone, intermittent abdominal daytime pressure ventilator device.

A4540

Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm

A4541

Monthly supplies for use of device coded at E0733

A4542

Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist

A4560

Neuromuscular electrical stimulator (NMES), disposable, replacement only

A4596

Cranial electrotherapy stimulation (CES) system supplies and accessories, per month

A5508

For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe

A5510

For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe

A6590

External urinary catheters; disposable, with wicking material, for use with suction pump, per month

A6591

External urinary catheter; nondisposable, for use with suction pump, per month

A9276

Sensor; invasive (e.g., subcutaneous), disposable, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM), one unit = one day supply

A9277

Transmitter; external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM)

A9278

Receiver (monitor); external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM)

E0492

Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application

E0493

Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply

E0530

Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type

E0677

Nonpneumatic sequential compression garment, trunk

E0732

Cranial electrotherapy stimulation (CES) system, any type

E0733

Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve

E0734

External upper limb tremor stimulator of the peripheral nerves of the wrist

E0735

Noninvasive vagus nerve stimulator

E0736

Transcutaneous tibial nerve stimulator

E0738

Upper extremity rehabilitation system providing active assistance to facilitate muscle reeducation, includes microprocessor, all components and accessories

E0739

Rehab system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors

E1301

Whirlpool tub, walk-in, portable

E2103

Nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver

E3000

Speech volume modulation system, any type, including all components and accessories

K1004

Low frequency ultrasonic diathermy treatment device for home use

93452

Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed