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Coverage criteria policies

Category III CPT codes – Minnesota Health Care Programs

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 is not required for Category III CPT codes. See the Coverage section below for details.

Coverage

Category III CPT Codes are not generally covered services and are not eligible for reimbursement under Minnesota Health Care Programs. However, Minnesota Health Care Programs will cover the following Category III Codes.

Codes

Description

0191T

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

0208T

Pure tone audiometry (threshold), automated; air only

0209T

Pure tone audiometry (threshold), automated; air and bone

0210T

Speech audiometry threshold, automated;

0211T

Speech audiometry threshold, automated; with speech recognition

0212T

Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated

0230T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level

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

0337T

Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral

0377T

Anoscopy with directed submucosal injection of bulking agent for fecal incontinence

0403T

Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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.

References

  1. MHCP Fee Schedule last accessed 5/9/18

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Policy activity

  • 12/09/2016 - Date of origin
  • 07/11/2017 - Effective date
Review date
  • 05/2018

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