Z-109-006

HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

Medical Policy:

Z-109-006

Topic:

Outpatient Surgery Site of Care

Section:

Miscellaneous

Effective Date:

July 27, 2026

Issued Date:

July 27, 2026

Last Revision Date:

July 2026

Annual Review:

February 2026

Surgeries can be performed safely in various settings. This policy addresses individual and procedural factors influencing the need for potential urgent hospital-level care during outpatient procedures, thereby determining the appropriate site of service. Possible locations include off-campus and on-campus hospital outpatient departments, inpatient hospitals, ambulatory surgical centers (ASCs), and physician offices, each with varying costs. To ensure safe, timely and cost-effective care for specific surgical procedures, medical necessity will be reviewed, prioritizing the least expensive appropriate setting (physician's office, ASC, then outpatient hospital) unless clinical or geographic contraindications exist.

Policy Position

The procedures identified within this policy will be considered medically necessary when performed in the lowest appropriate setting unless the following clinical or geographic contraindications are met:

Age <18 years; or
Nearest in-network non-hospital outpatient facility with procedural capabilities is >25 miles from patient’s home; or
Anesthesia risk including ANY of the following;
- American Society of Anesthesiologists (ASA) Physical Status (PS) Classification IV or higher (see definition); or
- History of complications from anesthesia (e.g., malignant hyperthermia); or
- Alcohol dependence at risk for withdrawal syndrome; or
- Recent history of drug abuse (e.g., cocaine) (<3 months); or
- Prolonged surgery (>3 hours); or
- Known or suspected difficult airway; or
Increased cardiovascular risk, including but not limited to:
- Uncompensated chronic heart failure (NYHA class III or IV) (see definition); or
- Recent history of myocardial infarction (MI) (<6 months); or
- Poorly controlled, resistant hypertension; or
- Recent history of cerebrovascular accident or transient ischemic attack (<3 months); or
- Increased risk for cardiac ischemia (cardiac or vascular stent placed <1 year or angioplasty <90 days); or
- Cardiac arrhythmia that increases periprocedural or anesthesia risk; or
- Moderate or severe valvular heart disease; or
- Implantable cardioverter-defibrillator (ICD); or
- Mechanical cardiovascular support (e.g., left ventricular assist device [LVAD] or total artificial heart); or
Increased pulmonary risk, including but not limited to:
- Moderate to severe chronic obstructive pulmonary disease (COPD) (FEV1 <50% or 2 or more exacerbations in the past year); or
- Moderate or severe persistent asthma (FEV1 <80% despite treatment); or
- Moderate to severe obstructive sleep apnea (OSA) (AHI or RDI ≥15); or
- Dependent on a ventilator; or
- Dependent on continuous supplemental oxygen; or
Increased liver risk, including but not limited to:
- Advanced liver disease (MELD Score >8); or
Increased renal risk, including but not limited to:
- End stage renal disease on dialysis; or
Increased bleeding risk, including but not limited to:
- Bleeding disorder requiring replacement factor, blood products, DDAVP/desmopressin, or special infusion product; or
- Anticipated need for transfusion(s); or
Other
- Morbid obesity (BMI ≥40); or
- Brittle diabetes or HbA1C ≥ 8.5%; or
- Pregnancy; or
- Cannot transfer independently; or
- Known or suspected foreign body in the target organ or tissue; or
- Significant cognitive impairment (e.g., unable to participate in pre-procedure planning and/or understand discharge instructions; or
Site of care clinical review will take into consideration whether:
- The treating network participating provider recommends, based on a written clinical justification submitted to Highmark, that the service be provided at a hospital-based outpatient clinic; or
- The member requested a particular network participating provider who performs the requested service in a hospital-based outpatient clinic because the member is undergoing a continuing course of treatment with the participating provider or because the member has previously obtained the requested service from the participating provider, and the provider is not credentialed at any free-standing ambulatory surgical center in the service area and is not able to be credentialed within ninety days following the submission of the authorization request to the health care plan.

Surgical Procedures Integumentary System

15780	DERMABRASION TOTAL FACE (EG FOR ACNE SCARRING FINE WRINKLING RHYTIDS GENERAL KERATOSIS)
15782	DERMABRASION REGIONAL OTHER THAN FACE
15783	DERMABRASION SUPERFICIAL ANY SITE (EG TATTOO REMOVAL)
15786	ABRASION SINGLE LESION (EG KERATOSIS SCAR)
15788	CHEMICAL PEEL FACIAL EPIDERMAL
15789	CHEMICAL PEEL FACIAL DERMAL
15792	CHEMICAL PEEL NON-FACIAL EPIDERMAL
15793	CHEMICAL PEEL NON-FACIAL DERMAL
15820	BLEPHAROPLASTY LOWER EYELID
15821	BLEPHAROPLASTY LOWER EYELID WITH EXTENSIVE HERNIATED FAT PAD
15822	BLEPHAROPLASTY UPPER EYELID
15823	BLEPHAROPLASTY UPPER EYELID WITH EXTENSIVE SKIN WEIGHTING DOWN LID
15839	EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY) OTHER AREAS
15877	SUCTION ASSISTED LIPECTOMY TRUNK
15878	SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY
15879	SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY
17106	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) LESS THAN 10 SQ CM
17107	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) 10.0- 50 SQ CM
17108	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) OVER 50 SQ CM
17999	UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE

Surgical Procedures on the Respiratory System

30130	EXCISION INFERIOR TURBINATE PARTIAL OR COMPLETE ANY METHOD
30420	RHINOPLASTY PRIMARY INCLUDING MAJOR SEPTAL REPAIR
30435	RHINOPLASTY SECONDARY INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES)
30520	SEPTOPLASTY OR SUBMUCOUS RESECTION WITH OR WITHOUT CARTILAGE SCORING CONTOURING OR REPLACEMENT WITH GRAFT
30630	REPAIR NASAL SEPTAL PERFORATIONS
31253	NASAL/SINUS ENDOSCOPY SURGICAL WITH ETHMOIDECTOMY TOTAL (ANTERIOR AND POSTERIOR) INCLUDING FRONTAL SINUS EXPLORATION WITH REMOVAL OF TISSUE FROM FRONTAL SINUS WHEN PERFORMED
31254	NASAL/SINUS ENDOSCOPY SURGICAL WITH ETHMOIDECTOMY PARTIAL (ANTERIOR)
31255	NASAL/SINUS ENDOSCOPY SURGICAL WITH ETHMOIDECTOMY TOTAL (ANTERIOR AND POSTERIOR)
31257	NASAL/SINUS ENDOSCOPY SURGICAL WITH ETHMOIDECTOMY TOTAL (ANTERIOR AND POSTERIOR) INCLUDING SPHENOIDOTOMY
31259	NASAL/SINUS ENDOSCOPY SURGICAL WITH ETHMOIDECTOMY TOTAL (ANTERIOR AND POSTERIOR) INCLUDING SPHENOIDOTOMY WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS
31295	NASAL/SINUS ENDOSCOPY SURGICAL WITH DILATION (EG BALLOON DILATION) MAXILLARY SINUS OSTIUM TRANSNASAL OR VIA CANINE FOSSA

Surgical Procedures on the Musculoskeletal System

20912	CARTILAGE GRAFT NASAL SEPTUM
21089	UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE
21110	APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION INCLUDES REMOVAL
22513	PERCUTANEOUS VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG KYPHOPLASTY) 1 VERTEBRAL BODY UNILATERAL OR BILATERAL CANNULATION INCLUSIVE OF ALL IMAGING GUIDANCE THORACIC
22514	PERCUTANEOUS VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG KYPHOPLASTY) 1 VERTEBRAL BODY UNILATERAL OR BILATERAL CANNULATION INCLUSIVE OF ALL IMAGING GUIDANCE LUMBAR
22515	PERCUTANEOUS VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG KYPHOPLASTY) 1 VERTEBRAL BODY UNILATERAL OR BILATERAL CANNULATION INCLUSIVE OF ALL IMAGING GUIDANCE EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22551	ARTHRODESIS ANTERIOR INTERBODY INCLUDING DISC SPACE PREPARATION DISCECTOMY OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS CERVICAL BELOW C2
22552	ARTHRODESIS ANTERIOR INTERBODY INCLUDING DISC SPACE PREPARATION DISCECTOMY OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS CERVICAL BELOW C2 EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR SEPARATE PROCEDURE)
22558	ARTHRODESIS ANTERIOR INTERBODY TECHNIQUE INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) LUMBAR
22585	ARTHRODESIS ANTERIOR INTERBODY TECHNIQUE INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22600	ARTHRODESIS POSTERIOR OR POSTEROLATERAL TECHNIQUE SINGLE INTERSPACE CERVICAL BELOW C2 SEGMENT
22612	ARTHRODESIS POSTERIOR OR POSTEROLATERAL TECHNIQUE SINGLE INTERSPACE LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE WHEN PERFORMED)
22614	ARTHRODESIS POSTERIOR OR POSTEROLATERAL TECHNIQUE SINGLE INTERSPACE EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22630	ARTHRODESIS POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY ANDOR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) SINGLE INTERSPACE LUMBAR
22633	ARTHRODESIS COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) SINGLE INTERSPACE LUMBAR
22634	ARTHRODESIS COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) SINGLE INTERSPACE EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22840	POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG ARRINGTON ROD TECHNIQUE PEDICLE FIXATION ACROSS 1 INTERSPACE ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION SUBLAMINAR WIRING AT C1 FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22842	POSTERIOR SEGMENTAL INSTRUMENTATION (EG PEDICLE FIXATION DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES) 3 TO 6 VERTEBRAL SEGMENTS (L IST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22845	ANTERIOR INSTRUMENTATION 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22854	INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG SYNTHETIC CAGE MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG SCREWS FLANGES) WHEN PERFORMED TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22856	INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG SYNTHETIC CAGE MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG SCREWS FLANGES) WHEN PERFORMED TO VERTEBRAL CORPECTOMY(IES) (VERTEBRAL BODY RESECTION PARTIAL OR COMPLETE) DEFECT IN CONJUNCTION WITH INTERBODY ARTHRODESIS EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22858	TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTERIOR APPROACH INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION) SINGLE INTERSPACE CERVICAL
22870	TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTERIOR APPROACH INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION) SECOND LEVEL CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22899	INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE WITHOUT OPEN DECOMPRESSION OR FUSION INCLUDING IMAGE GUIDANCE WHEN PERFORMED LUMBAR SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
23000	UNLISTED PROCEDURE SPINE
23020	REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS OPEN
23120	CAPSULAR CONTRACTURE RELEASE (EG SEVER TYPE PROCEDURE)
23130	CLAVICULECTOMY PARTIAL
23410	ACROMIOPLASTY OR ACROMIONECTOMY PARTIAL WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE
23412	REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF) OPEN/ACUTE
23415	REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG ROTATOR CUFF) OPEN CHRONIC
23420	CORACOACROMIAL LIGAMENT RELEASE WITH OR WITHOUT ACROMIOPLASTY
23430	RECONSTRUCTION OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION CHRONIC (INCLUDES ACROMIOPLASTY)
23440	TENODESIS OF LONG TENDON OF BICEPS
23450	RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS
23455	CAPSULORRHAPHY ANTERIOR PUTTIPLATT PROCEDURE OR MAGNUSON TYPE OPERATION
23462	CAPSULORRHAPHY ANTERIOR WITH LABRAL REPAIR (EG BANKART PROCEDURE)
23470	CAPSULORRHAPHY ANTERIOR ANY TYPE WITH CORACOID PROCESS TRANSFER
23472	ARTHROPLASTY GLENOHUMERAL JOINT HEMIARTHROPLASTY
27096	ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG TOTAL SHOULDER))
27130	INJECTION PROCEDURE FOR SACROILIAC JOINT ANESTHETIC/STEROID WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED
27279	ARTHROPLASTY ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY) WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
27403	ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION) WITH IMAGE GUIDANCE INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED AND PLACEMENT OF TRANSFIXING DEVICE
27412	ARTHROTOMY WITH MENISCUS REPAIR KNEE
27415	AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE
27416	OSTEOCHONDRAL ALLOGRAFT KNEE OPEN
27418	OSTEOCHONDRAL AUTOGRAFT(S) KNEE OPEN (EG MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFTS)
27420	ANTERIOR TIBIAL TUBERCLEPLASTY (EG MAQUET TYPE PROCEDURE)
27422	RECONSTRUCTION OF DISLOCATING PATELLA (EG HAUSER TYPE PROCEDURE)
27427	RECONSTRUCTION OF DISLOCATING PATELLA WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG AMPBELL GOLDWAITE TYPE PROCEDURE)
27428	LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE EXTRAARTICULAR
27438	LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE INTRAARTICULAR (OPEN)
27446	ARTHROPLASTY PATELLA WITH PROSTHESIS
27447	ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL OR LATERAL COMPARTMENT
27599	ARTHROPLASTY KNEE CONDYLE AND PLATEAU MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)
28110	UNLISTED PROCEDURE FEMUR OR KNEE
28291	OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)
28295	HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT WITH IMPLANT
28296	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH PROXIMAL METATARSAL OSTEOTOMY ANY METHOD
28297	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH DISTAL METATARSAL OSTEOTOMY ANY METHOD
28299	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS ANY METHOD
28306	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH DOUBLE OSTEOTOMY ANY METHOD
28322	OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION METATARSAL FIRST METATARSAL
28755	REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)
29805	ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT
29806	ARTHROSCOPY SHOULDER DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)
29807	ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY
29819	ARTHROSCOPY SHOULDER SURGICAL REPAIR OF SLAP LESION
29820	ARTHROSCOPY SHOULDER SURGICAL WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY
29821	ARTHROSCOPY SHOULDER SURGICAL SYNOVECTOMY PARTIAL
29822	ARTHROSCOPY SHOULDER SURGICAL SYNOVECTOMY COMPLETE
29823	ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT LIMITED 1 OR 2 DISCRETE STRUCTURES (EG HUMERAL BONE HUMERAL ARTICULAR CARTILAGE GLENOID BONE GLENOID ARTICULAR CARTILAGE BICEPS TENDON BICEPS ANCHOR COMPLEX LABRUM ARTICULAR CAPSULE ARTICULAR SIDE OF THE ROTATOR CUFF BURSAL SIDE OF THE ROTATOR CUFF SUBACROMIAL BURSA FOREIGN BODIES)
29824	ARTHROSCOPY SHOULDER SURGICAL DEBRIDEMENT EXTENSIVE 3 OR MORE DISCRETE STRUCTURES (EG HUMERAL BONE HUMERAL ARTICULAR CARTILAGE GLENOID BONE GLENOID ARTICULAR CARTILAGE BICEPS TENDON BICEPS ANCHOR COMPLEX LABRUM ARTICULAR CAPSULE ARTICULAR SIDE OF THE ROTATOR CUFF BURSAL SIDE OF THE ROTATOR CUFF SUBACROMIAL BURSA FOREIGN BODIES)
29825	ARTHROSCOPY SHOULDER SURGICAL DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)
29826	ARTHROSCOPY SHOULDER SURGICAL WITH LYSIS AND RESECTION OF ADHESIONS WITH OR WITHOUT MANIPULATION
29827	ARTHROSCOPY SHOULDER SURGICAL DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY WITH CORACOACROMIAL LIGAMENT (IE ARCH) RELEASE WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
29828	ARTHROSCOPY SHOULDER SURGICAL WITH ROTATOR CUFF REPAIR
29860	ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS
29861	ARTHROSCOPY HIP DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)
29862	ARTHROSCOPY HIP SURGICAL WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY
29863	ARTHROSCOPY HIP SURGICAL WITH DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) ABRASION ARTHROPLASTY AND/OR RESECTION OF LABRUM
29870	ARTHROSCOPY HIP SURGICAL WITH SYNOVECTOMY
29873	ARTHROSCOPY KNEE DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROC)
29874	ARTHROSCOPY KNEE SURGICAL WITH LATERAL RELEASE
29875	ARTHROSCOPY KNEE SURGICAL FOR REMOVAL OF LOOSE OR FOREIGN BODY (EG OSTEOCHONDRITIS DISSECANS FRAGMENTATION CHONDRAL FRAGMENTATION)
29876	ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY LIMITED (EG PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)
29877	ARTHROSCOPY KNEE SURGICAL SYNOVECTOMY MAJOR 2 OR MORE COMPARTMENTS (EG MEDIAL OR LATERAL)
29879	ARTHROSCOPY KNEE SURGICAL DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)
29880	ARTHROSCOPY KNEE SURGICAL ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE
29881	ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL AND LATERAL INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) SAME OR SEPARATE COMPARTMENT(S) WHEN PERFORMED
29882	ARTHROSCOPY KNEE SURGICAL WITH MENISCECTOMY (MEDIAL OR LATERAL INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) SAME OR SEPARATE COMPARTMENT(S) WHEN PERFORMED
29883	ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL OR LATERAL)
29884	ARTHROSCOPY KNEE SURGICAL WITH MENISCUS REPAIR (MEDIAL AND LATERAL)
29885	ARTHROSCOPY KNEE SURGICAL WITH LYSIS OF ADHESIONS WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)
29886	ARTHROSCOPY KNEE SURGICAL DRILLING FOR OSTEOCHONDRITIS DISSECANS WITH BONE GRAFTING WITH OR WITHOUT INTERNAL FIXATION INCLUDING DEBRIDEMENT OF BASE OF LESION)
29887	ARTHROSCOPY KNEE SURGICAL DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LESION
29888	ARTHROSCOPY KNEE SURGICAL DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LESION WITH INTERNAL FIXATION
29889	ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION
29892	ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION
29899	ARTHROSCOPICALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS DISSECANS LESION TALAR DOME FRACTURE OR TIBIAL PLAFOND FRACTURE WITH OR WITHOUT INTERNAL FIXATION (INCLUDES ARTHROSCOPY)
29914	ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURGICAL WITH ANKLE ARTHRODESIS
29915	ARTHROSCOPY HIP SURGICAL WITH FEMOROPLASTY (IE TREATMENT OF CAM LESION)
29916	ARTHROSCOPY HIP SURGICAL WITH ACETABULOPLASTY (IE TREATMENT OF PINCER LESION)
29999	ARTHROSCOPY HIP SURGICAL WITH LABRAL REPAIR
	UNLISTED PROCEDURE ARTHROSCOPY

Surgical Procedures on the Cardiovascular System

33285	INSERTION SUBCUTANEOUS CARDIAC RHYTHM MONITOR INCLUDING PROGRAMMING
36465	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING SINGLE INCOMPETENT EXTREMITY TRUNCAL VEIN (EG GREAT SAPHENOUS VEIN ACCESSORY SAPHENOUS VEIN)
36466	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING MULTIPLE INCOMPETENT TRUNCAL VEINS (EG GREAT SAPHENOUS VEIN ACCESSORY SAPHENOUS VEIN) SAME LEG
36470	INJECTION OF SCLEROSANT SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA)
36471	INJECTION OF SCLEROSANT MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA) SAME LEG
36473	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS MECHANOCHEMICAL FIRST VEIN TREATED
36475	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS RADIOFREQUENCY FIRST VEIN TREATED
36476	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS RADIOFREQUENCY SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
36478	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS LASER FIRST VEIN TREATED
36479	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS LASER SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)’
36482	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS FIRST VEIN TREATED
36483	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Surgical Procedures on the Digestive System

42821	TONSILLECTOMY AND ADENOIDECTOMY AGE 12 OR OVER
42826	TONSILLECTOMY PRIMARY OR SECONDARY AGE 12 OR OVER
42831	ADENOIDECTOMY PRIMARY AGE 12 OR OVER
43774	LAPAROSCOPY SURGICAL GASTRIC RESTRICTIVE PROCEDURE REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS
43775	LAPAROSCOPY SURGICAL GASTRIC RESTRICTIVE PROCEDURE LONGITUDINAL GASTRECTOMY (IE SLEEVE GASTRECTOMY)

Surgical Procedures on the Urinary System

55899

UNLISTED PROCEDURE MALE GENITAL SYSTEM

Surgical Procedures on the Nervous System

62320	INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG ANESTHETIC ANTISPASMODIC OPIOID STEROID OTHER SOLUTION) NOT INCLUDING NEUROLYTIC SUBSTANCES INCLUDING NEEDLE OR CATHETER PLACEMENT INTERLAMINAR EPIDURAL OR SUBARACHNOID CERVICAL OR THORACIC WITHOUT IMAGING GUIDANCE
62321	INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG ANESTHETIC ANTISPASMODIC OPIOID STEROID OTHER SOLUTION) NOT INCLUDING NEUROLYTIC SUBSTANCES INCLUDING NEEDLE OR CATHETER PLACEMENT INTERLAMINAR EPIDURAL OR SUBARACHNOID CERVICAL OR THORACIC WITH IMAGING GUIDANCE (IE FLUOROSCOPY OR CT)
62322	INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG ANESTHETIC ANTISPASMODIC OPIOID STEROID OTHER SOLUTION) NOT INCLUDING NEUROLYTIC SUBSTANCES INCLUDING NEEDLE OR CATHETER PLACEMENT INTERLAMINAR EPIDURAL OR SUBARACHNOID LUMBER OR SACRAL (CAUDAL) WITHOUT IMAGING GUIDANCE
62323	INJECTION(S) OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG ANESTHETIC ANTISPASMODIC OPIOID STEROID OTHER SOLUTION) NOT INCLUDING NEUROLYTIC SUBSTANCES INCLUDING NEEDLE OR CATHETER PLACEMENT INTERLAMINAR EPIDURAL OR SUBARACHNOID LUMBER OR SACRAL (CAUDAL) WITH IMAGING GUIDANCE (IE FLUOROSCOPY OR CT)
62350	IMPLANTATION REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER FOR LONG TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP WITHOUT LAMINECTOMY
62362	IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION PROGRAMMABLE PUMP INCLUDING PREPARATION OF PUMP WITH OR WITHOUT PROGRAMMING
62380	ENDOSCOPIC DECOMPRESSION OF SPINAL CORD NERVE ROOT(S) INCLUDING LAMINOTOMY PARTIAL FACETECTOMY FORAMINOTOMY DISCECTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC 1 INTERSPACE LUMBAR
63030	LAMINOTOMY (HEMILAMINECTOMY) WITH DECOMPRESSION OF NERVE ROOT(S) INCLUDING PARTIAL FACETECTOMY FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC 1 INTERSPACE LUMBAR
63035	LAMINOTOMY (HEMILAMINECTOMY) WITH DECOMPRESSION OF NERVE ROOT(S) INCLUDING PARTIAL FACETECTOMY FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC EACH ADDITIONAL INTERSPACE CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
63042	LAMINOTOMY (HEMILAMINECTOMY) WITH DECOMPRESSION OF NERVE ROOT(S) INCLUDING PARTIAL FACETECTOMY FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISK RE-EXPLORATION SINGLE INTERSPACE LUMBAR
63056	TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD EQUINA AND/OR NERVE ROOT(S) (EG HERNIATED INTERVERTEBRAL DISK) SINGLE SEGMENT LUMBAR (INCLUDING TRANSFACET OR LATERAL EXTRAFORAMINAL APPROACH) (EG FAR LATERAL HERNIATED INTERVERTEBRAL DISK)
63650	PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY EPIDURAL
63655	LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES PLATE/PADDLE EPIDURAL
63663	REVISION INCLUDING REPLACEMENT WHEN PERFORMED OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S) INCLUDING FLUOROSCOPY WHEN PERFORMED
63664	REVISION INCLUDING REPLACEMENT WHEN PERFORMED OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY INCLUDING FLUOROSCOPY WHEN PERFORMED
63685	INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
64479	INJECTION(S) ANESTHETIC AGENT AND/OR STEROID TRANSFORAMINAL EPIDURAL WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC SINGLE LEVEL
64480	INJECTION(S) ANESTHETIC AGENT AND/OR STEROID TRANSFORAMINAL EPIDURAL WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64483	INJECTION(S) ANESTHETIC AGENT AND/OR STEROID TRANSFORAMINAL EPIDURAL WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL SINGLE LEVEL
64484	INJECTION(S) ANESTHETIC AGENT AND/OR STEROID TRANSFORAMINAL EPIDURAL WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64490	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC SINGLE LEVEL
64491	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64492	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64493	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL SINGLE LEVEL
64494	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64495	INJECTION(S) DIAGNOSTIC OR THERAPEUTIC AGENT PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64510	INJECTION ANESTHETIC AGENT STELLATE GANGLION (CERVICAL SYMPATHETIC)
64520	INJECTION ANESTHETIC AGENT LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)
64561	PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE IF PERFORMED
64582	OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY PULSE GENERATOR AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY
64590	INSERTION OR REPLACEMENT OF PERIPHERAL SACRAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
64633	DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVE(S) WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC SINGLE FACET JOINT
64634	DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVE(S) WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) CERVICAL OR THORACIC EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64635	DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVE(S) WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL SINGLE FACET JOINT
64636	DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVE(S) WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Surgical Procedures on the Eye and Ocular Adnexa

66989	EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1STAGE PROCEDURE) MANUAL OR MECHANICAL TECHNIQUE (EG IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) COMPLEX REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG IRIS EXPANSION DEVICE SUTURE SUPPORT FOR INTRAOCULAR LENS OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE WITH INSERTION OF INTRAOCULAR (EG TRABECULAR MESHWORK SUPRACILIARY SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE WITHOUT EXTRAOCULAR RESERVOIR INTERNAL APPROACH ONE OR MORE
66991	EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE) MANUAL OR MECHANICAL TECHNIQUE (EG IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) WITH INSERTION OF INTRAOCULAR (EG TRABECULAR MESHWORK SUPRACILIARY SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE WITHOUT EXTRAOCULAR RESERVOIR INTERNAL APPROACH ONE OR MORE
67900	REPAIR OF BROW PTOSIS (SUPRACILIARY MIDFOREHEAD OR CORONAL APPROACH)
67901	REPAIR OF BLEPHAROPTOSIS FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG BANKED FASCIA)
67902	REPAIR OF BLEPHAROPTOSIS FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67903	REPAIR OF BLEPHAROPTOSIS (TARSO) LEVATOR RESECTION OR ADVANCEMENT INTERNAL APPROACH
67904	REPAIR OF BLEPHAROPTOSIS (TARSO) LEVATOR RESECTION OR ADVANCEMENT EXTERNAL APPROACH
67908	REPAIR OF BLEPHAROPTOSIS CONJUNCTIVO-TARSO-MULLER S MUSCLE-LEVATOR RESECTION (EG FASANELLA-SERVAT TYPE)
67911	CORRECTION OF LID RETRACTION
67999	UNLISTED PROCEDURE EYELIDS
68899	UNLISTED PROCEDURE LACRIMAL SYSTEM

Assorted Devices, Implants, and Systems

C1820	GENERATOR NEUROSTIMULATOR (IMPLANTABLE) NON-HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM
C1822	GENERATOR NEUROSTIMULATOR (IMPLANTABLE) HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM

Other Therapeutic Services and Supplies

C9757

LAMINOTOMY (HEMILAMINECTOMY) WITH DECOMPRESSION OF NERVE ROOT(S) INCLUDING PARTIAL FACETECTOMY FORAMINOTOMY AND EXCISION OF HERNIATED INTERVERTEBRAL DISC AND REPAIR OF ANNULAR DEFECT WITH IMPLANTATION OF BONE ANCHORED ANNULAR CLOSURE DEVICE INCLUDING ANNULAR DEFECT MEASUREMENT ALIGNMENT AND SIZING ASSESSMENT AND IMAGE GUIDANCE 1 INTERSPACE LUMBAR

Miscellaneous Diagnostic and Therapeutic Services

G0260

INJECTION PROCEDURE FOR SACROILIAC JOINT PROVISION OF ANESTHETIC STERIOD AND/OR OTHER THERAPEUTIC AGENT AND ARTHROGRAPHY

All procedure codes on this policy are managed by Highmark

15780	15782	15783	15786	15788	15789	15792
15793	15820	15821	15822	15823	15830	15839
15847	15877	15878	15879	17106	17107	17108
17999	19318	20912	21089	21110	22513	22514
22515	22551	22552	22558	22585	22600	22612
22614	22630	22633	22634	22840	22842	22845
22853	22854	22856	22858	22870	22899	23000
23020	23120	23130	23410	23412	23415	23420
23430	23440	23450	23455	23462	23470	23472
27096	27130	27279	27403	27412	27415	27416
27418	27420	27422	27427	27428	27438	27446
27447	27599	28110	28291	28295	28296	28297
28299	28306	28322	28755	29805	29806	29807
29819	29820	29821	29822	29823	29824	29825
29826	29827	29828	29860	29861	29862	29863
29870	29873	29874	29875	29876	29877	29879
29880	29881	29882	29883	29884	29885	29886
29887	29888	29889	29892	29899	29914	29915
29916	29999	30130	30420	30435	30520	30630
31253	31254	31255	31257	31259	31295	33285
36465	36466	36470	36471	36473	36475	36476
36478	36479	36482	36483	37243	37700	37761
37765	37766	37799	42821	42826	42831	43774
43775	55899	62320	62321	62322	62323	62350
62362	62380	63030	63035	63042	63056	63650
63655	63663	63664	63685	64479	64480	64483
64484	64490	64491	64492	64493	64494	64495
64510	64520	64561	64582	64590	64633	64634
64635	64636	66989	66991	67900	67901	67902
67903	67904	67908	67911	67999	68899	C1820
C1822	C9757	G0260

Related Policies

Refer to Medical Policy I-151, Site of Care, for additional information.

Refer to Medical Policy S-278, Blepharoplasty, Repair of Blepharoptosis, and Repair of Brow Ptosis, for additional information.

Refer to Medical Policy S-28, Cosmetic vs Reconstructive Surgery, for additional information.

Refer to Medical Policy M-77, Upper Gastrointestinal Endoscopy/Esophagoscopy, for additional information.

Refer to Medical Policy S-184, Gender Affirmation Treatment, for additional information.

Refer to Medical Policy S-201, Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents for additional information.

Refer to Medical Policy S-284, Ankle Arthroscopy, for additional information.

Refer to Medical Policy S-337, Arthrodesis, Interphalangeal Joint, for additional information.

Refer to Medical Policy, Shoulder Arthroplasty (Total, Hemi, Reverse)/Arthrodesis, for additional information.

Refer to Medical Policy S-255, Lumbar Fusion (Arthrodesis) for additional information.

Refer to Medical Policy S-324, Spinal Fusion, Thoracic and Thoracolumbar, for additional information. Refer to Medical Policy S-36, Treatment of Benign or Premalignant Skin Conditions for additional information.

Refer to Medical Policy S-280, Surgical Treatment of Obstructive Sleep Apnea, for additional information.

Refer to Medical Policy S-55, Surgical Treatment of Varicose Veins, for additional information.

Refer to Medical Policy S-552, Sclerotherapy (Liquid or Microfoam), for additional information.

Refer to Medical Policy, S-258, Spinal Cord and Implantable Peripheral Nerve Stimulators, for additional information.

Refer to Medical Policy S-385, Spinal Cord and Dorsal Root Ganglion Stimulation, for additional information.

Refer to Medical Policy S-285, Spinal Cord and Dorsal Root Ganglion Stimulation, for additional information.

Refer to Medical Policy S-40, Implantable Intrathecal Drug Delivery Systems, for additional information.

Refer to Medical Policy S-331, Bariatric Surgery, for additional information.

Refer to Medical Policy R-15, Selective Internal Radiation Therapy (SIRT)/Radioembolization, for additional information.

Refer to Medical Policy S189, Epidural Steroid Injections, for additional information.

Refer to Medical Policy S-97, Treatment of the Prostate, for additional information.

Refer to Medical Policy S-275, Prostate Disease: Diagnosis, Staging, and Treatment, for additional information.

Refer to Medical Policy Z-61, Facet Joint Injections/Medial Branch Blocks, for additional information.

Refer to Medical Policy S-185, Knee Surgery – Arthroscopic and Open Procedure, for additional information.

Refer to Medical Policy S-150, Radiofrequency Joint Ablation-Denervation, for additional information.

Refer to Medical Policy S-131, Sacral Nerve Neuromodulation, for additional information.

Professional Statements and Societal Positions Guidelines

American Society of Anesthesiology (ASA) Physical Status (PS) Classification:

ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

Brittle diabetes: Diabetes that is difficult to control due to symptoms such as predominant hyperglycemia with recurrent ketoacidosis, predominant hypoglycemia, and mixed hyper- and hypo-glycemia.

New York Heart Association (NYHA) Functional Classification:

Class I No limitation of physical activity
Class II Slight limitation of physical activity
Class III Marked limitation of physical activity
Class IV Unable to carry on any physical activity

Obstructive sleep apnea (OSA): A sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort.

All procedure codes on this policy are managed by Highmark

15780	15782	15783	15786	15788	15789	15792
15793	15820	15821	15822	15823	15839	15877
15878	15879	17106	17107	17108	17999	20912
21089	21110	22513	22514	22515	22551	22552
22558	22585	22600	22612	22614	22630	22633
22634	22840	22842	22845	22853	22854	22856
22858	22870	22899	23000	23020	23120	23130
23410	23412	23415	23420	23430	23440	23450
23455	23462	23470	23472	27096	27130	27279
27403	27412	27415	27416	27418	27420	27422
27427	27428	27438	27446	27447	27599	28110
28291	28295	28296	28297	28299	28306	28322
28755	29805	29806	29807	29819	29820	29821
29822	29823	29824	29825	29826	29827	29828
29860	29861	29862	29863	29870	29873	29874
29875	29876	29877	29879	29880	29881	29882
29883	29884	29885	29886	29887	29888	29889
29892	29899	29914	29915	29916	29999	30130
30420	30435	30520	30630	31253	31254	31255
31257	31259	31295	33285	36465	36466	36470
36471	36473	36475	36476	36478	36479	36482
36483	37243	37700	37761	37765	37766	37799
42821	42826	42831	43774	43775	55899	62320
62321	62322	62323	62350	62362	62380	63030
63035	63042	63056	63650	63655	63663	63664
63685	64479	64480	64483	64484	64490	64491
64492	64493	64494	64495	64510	64520	64561
64582	64590	64633	64634	64635	64636	66989
66991	67900	67901	67902	67903	67904	67908
67911	67999	68899	C1820	C1822	C9757	G0260

Place of Service: Inpatient/Outpatient

Site of care is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Evidence-based guidelines support the choice of site of care.

The policy position applies to all commercial lines of insured business and, if elected, ASO.

Links

Link to Provider Resource Center for the Medical Policy Update

4/2025, New Policy Z-109 Established for Site of Care

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.