0315T - TMHP ie Checked STAR in GOLD- Code not in non covered SG 10.12.18 AR STAR - Codes moved to PA term. AR 10.12.18 Removed in GOLD. AR 10.12.18 Added term date in CPT / Svccode table of 12/31/2015 STAR - Not in STAR non covered SG. AR 10.12.18 This code is configured in STAR beneit term MED ALLERGY IMMUNOTHERAPY ADMIN and set to require PA in GOLD Validated not in Medicaid Non Covered list - GOLD AR 10.17.18 Yes, code in w/PA benefit terms - AR 10.17.18 Validated in w PA term. AR 10.17.18 Validated still listed in TMHP Medicaid Non Covered Per TMH Manual may be reimbursed, verify in QNXT, does not show up in Ben Term Sheet Star Per Amysis not a covered MA , Deny XZ, Verify in QNXT does not show in Noncovered for STAR - add to Medicaid Non Covered List Per Amysis not a covered MA , Deny XZ, Verify in QNXT does not show in Noncovered for STAR Per TMH is a covered service w/ Auth - need to remove from noncovered in QNXT for STAR - COMPLETE Per TMHP Manual is covered w/ auth- Remove from QNXT Noncovered list - COMPLETE QNXT set up under BEN AUTH SURGERY Cosmetic is that okay? Per TMHP Manual maybe covered for injury or trauma - Remove from QNXT Noncovered List - COMPLETE PER TMHP Manual is limited to 2 svc per lifetime (only for breast reconstruction)- Remove from QNXT is noncovered, PA flag set in QNXT for STAR - COMPLETE PER TMHP Manual is limited to 2 svc per lifetime (only for breast reconstruction)- Remove from QNXT noncovered, PA flag set in QNXT for STAR - COMPLETE Per TMHP Manual is covered - Remove from QNXT noncovered - COMPLETE Remove from QNXT noncovered - is set for PA on STAR Term - COMPLETE Noncovered for STAR - Should be added to QNXT noncovered - COMPLETE Remove from QNXT noncovered - is set for PA on STAR Term - COMPLETE. Remove from noncovered list QNXT Need to remove from QNXT non covered Need to removed from QNXT Noncovered - Needs PA Set Need to set PA Flag in QNXT Needs to be added to PA QNXT - is covered per TMHP - is on Noncovered list for QNXT Add to STAR TMHP Non Covered SG - Ann 10.12.18 Removed code form STAR TMHP Non Covered SG Added to CHIP Non Covered SG 10.17.18 AR Code added to PA terms in GOLD 10.17.18 AR Validated STAR TMHP Non Covered SG…. Code is Not listed in GOLD AR 10.17.18 I see it listed as Non Covered for Commercial fg CPT Codes Descriptions PA Set in QNXT Yes or No Oncology drugs when utilized for off label use UFCP UFCP ONLY Video EEG Monitoring Unlisted laparoscopy procedure, biliary tract Unlisted procedure, stomach Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator Vagus nerve blocking therapy (morbid obesity); removal of pulse generator Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed Face-to-face behavioral counseling for obesity, 15 minutes Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes Cancer Chemotherapy: requires preauthorization for allowable charges >$500 per dose Out-of -Network Bone Growth Stimulators Long Term Support Services (LTSS) – per State benefit Gastrectomy, total; with esophagoenterostomy with Roux-hyphenen-hyphenY reconstruction with formation of intestinal pouch, any type Gastrectomy, partial, distal; with gastroduodenostomy with gastrojejunostomy with formation of intestinal pouch Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary procedure) Biopsy of liver, needle; percutaneous [in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes, enlarged liver)] Biopsy of liver, needle; when done for indicated purpose at tine of other major procedure (list separately in addition to code for primary procedure) [in the absence of signs or symptoms of liver disease (e.g., elevated liver disease, enlarged liver)] Biopsy of liver, wedge [in the absence of signs or symptoms of liver disease (e.g., elevated liver disease, enlarged liver)] Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography Cholecystectomy with exploration of common duct; with choledochoenterostomy Cholecystectomy with exploration of common duct; Cholecystectomy; with cholangiography Cholecystectomy; Laparoscopy, surgical; cholecystoenterostomy Laparoscopy, surgical; cholecystectomy with exploration of common duct Laparoscopy, surgical; cholecystectomy with cholangiography Laparoscopy, surgical; cholecystectomy Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline Weight management classes, non-hyphenphysician provider, per session Exercise classes, non-hyphenphysician provider, per session Nutrition classes, non-hyphenphysician provider, per session Per 2019 Auth List Obesity Treatment and Surgery - ALL obesity treatment and surgery must be performed at University Hospital See important Endnotes. STAR

This procedure appears on the selected insurer prior authorization source.