00103 - Experimental/Investigational Services Pain Management Therapy/Rehabilitation Transplant Wound Care Ambulatory / Surgical Procedures Imaging Services/ Diagnostic Procedures Nursing Services (including initial evaluations) Abortion (According to HHSC guidelines) Dental Oral maxillofacial surgery (including orthognathic surgery) Dental extractions/rehabilitation in members 0-6 years old and children > 13 years and above and all third molars (general anesthesia and facility) – For all other members that do not fall in these age ranges, follow HHSC guidelines. Otoplasty (including Microtia repair) Rhinoplasty/Septoplasty Scar Revision Vagus Nerve Stimulation Varicose Vein Treatment Hysterectomy Bariatric Surgery - Codes Blepharoplasty Implantable devices (e.g. Interspinous Process Decompressors) – includes trials Mammoplasty (Male, Female) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery) Blepharoplasty, lower eyelid; Blepharoplasty, lower eyelid; with extensive herniated fat pad Blepharoplasty, upper eyelid; Blepharoplasty, upper eyelid; with excessive skin weighting down lid Canthoplasty (reconstruction of canthus) CPT Book Closure of vesicouterine fistula; with hysterectomy Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) Vaginal hysterectomy, for uterus 250 g or less; Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele Vaginal hysterectomy, with total or partial vaginectomy; Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele Vaginal hysterectomy, radical (Schauta type operation) Vaginal hysterectomy, for uterus greater than 250 g; Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 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 t Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated 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 fo Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) 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) Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions Ligation, division, and/or excision of varicose vein cluster(s), 1 leg Allergen Immunotherapy Services

This procedure appears on the selected insurer prior authorization source.