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Coverage criteria policies

Category III CPT codes

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization requirements vary for Category III CPT codes. See the Coverage section below for details.

Coverage

Category III CPT codes generally require prior authorization unless otherwise stated on an applicable HealthPartners coverage policy.

Services associated with some Category III CPT codes have been determined to be investigational. Prior authorization is not applicable to Investigational Services because they are not eligible for coverage. Please refer to the Investigational Services-List of Non-Covered Services policy for Category III CPT Codes that are not covered.

The following Category III Codes do not require prior authorization and are generally covered subject to any limitations or exclusions in your plan documents.

Codes

Description

0042T

Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

0054T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)

0055T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)

0184T

Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, full thickness)

0191T

Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork

0234T

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery

0235T

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel

0236T

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta

0237T

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel

0238T

Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel

0249T

Transanal hemorrhoidal de-arterialization (THD) Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance

0253T

Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space

0254T

Endovascular repair of iliac artery bifurcation

0290T

Corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar keratoplasty

0295T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation

0296T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation

0297T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report

0298T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation

0330T

Tear film imaging, unilateral or bilateral

0342T

Therapeutic apheresis with selective HDL delipidation and plasma reinfusion

0362T

Behavior identification supporting assessment, each 15 min

0376T

Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure)

0399T

Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics)

0437T

Implant non-biologic or synthetic implant for fascial reinforcement of abdominal wall

0439T

Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)

0449T

0450T

Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into subconjunctival space; initial device (e.g. XEN gel stent)

0479T

Fractional ablative laser fenestration of burn and traumatic scars 1st 100 sq cm

0480T

Fractional ablative laser fenestration of burn and traumatic scars each additionall 100 sq cm

0482T

Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure)

0505T

Endovenous femoral artery revascularization, with stent- includes all ipsilateral selective arterial and venous catheterization, all diagnostic imaging for ipsilateral, lower extremity arteriography, and all related radiological supervision and interpretation

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Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 05/19/2011 - Date of origin
  • 07/08/2019 - Effective date
Review date
  • 05/2019
Revision date
  • 07/08/2019

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