Prior authorization codes
Medica
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0002M | Biochemical Biomarker Biochemical Biomarker Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0003M | Biochemical Biomarker Biochemical Biomarker Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0038U | Vitamin D Testing for Vitamin D Testing for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0042T | • CT or MR | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0052U | Testing for Screening, Testing for Screening | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0071T | High Intensity Focused High Intensity Focused Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0072T | High Intensity Focused High Intensity Focused Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 00796 | 47140, 47141, 47142, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0083U | In Vitro In Vitro Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0095T | feasible) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0098T | Sacroiliac Joint 0201T | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0101T | Extracorporeal Shock Extracorporeal Shock Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0102T | Extracorporeal Shock Extracorporeal Shock Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0106T | Quantitative Sensory Quantitative Sensory Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0107T | Quantitative Sensory Quantitative Sensory Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0108T | Quantitative Sensory Quantitative Sensory Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0109T | Tests MP9727 Tests MP9727 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0110T | Tests MP9727 Tests MP9727 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0126T | Procedures and Procedures and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0164T | Sacroiliac Joint 0201T | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0165T | Sacroiliac Joint 0201T | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0166U | Panel for Assessment Panel for Assessment HCPCS codes | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0200T | Sacroiliac Joint 0201T | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0201T | Sacroiliac Joint | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0202T | Posterior Inter- Posterior Inter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0206T | Services MP9415 Services MP9415 0265T, 0341T, 0397T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0207T | Meibomian Gland Meibomian Gland Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0213T | bral Facet | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0214T | Carelon. Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0215T | Carelon. Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0216T | Carelon. Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0217T | Medial | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0218T | Medial | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0219T | actual policy is needed to actual policy is needed to 0220T, 0221T, 0222T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0220T | actual policy is needed to actual policy is needed to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0221T | actual policy is needed to actual policy is needed to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0222T | actual policy is needed to actual policy is needed to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0232T | Autologous Blood- Autologous Blood- Not Covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0263T | Services MP9415 Services MP9415 0265T, 0341T, 0397T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0264T | Services MP9415 Services MP9415 0265T, 0341T, 0397T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0265T | Services MP9415 Services MP9415 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0266T | determine whether the determine whether the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0267T | determine whether the determine whether the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0268T | determine whether the determine whether the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0269T | procedure/service you procedure/service you | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0270T | procedure/service you procedure/service you | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0271T | procedure/service you procedure/service you | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0272T | are intending to request are intending to request | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0273T | are intending to request are intending to request | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0275T | mild® Procedure mild® Procedure Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0278T | Scrambler Pain Scrambler Pain Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0312T | Vagus Nerve Vagus Nerve Required , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0313T | Vagus Nerve Vagus Nerve Required , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0314T | Vagus Nerve Vagus Nerve Required , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0315T | Stimulation (VNS), Stimulation (VNS) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0316T | Stimulation (VNS), Stimulation (VNS) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0317T | Stimulation (VNS), Stimulation (VNS) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0335T | coverage in specific coverage in specific | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0341T | Services MP9415 Services MP9415 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0358T | Bioimpedance Bioimpedance Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0377U | Testing for Screening, Testing for Screening | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0397T | Confocal Laser Confocal Laser Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0398T | High Intensity Focused High Intensity Focused Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0437T | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0446T | Continuous Glucose Continuous Glucose Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0447T | Continuous Glucose Continuous Glucose Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0448T | Continuous Glucose Continuous Glucose Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0481T | Autologous Blood- Autologous Blood- Not Covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0494T | S2060, S2061, 32850, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0495T | S2060, S2061, 32850, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0496T | S2060, S2061, 32850, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0505T | Cardiology - Cardiology - Required through , , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0507T | Intense Pulsed Light Intense Pulsed Light Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0510T | are intending to request are intending to request | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0511T | has been identified as E/I has been identified as E/I 0624T, 0625T, 0658T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0512T | Wave Therapy Wave Therapy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0513T | Wave Therapy Wave Therapy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0524T | Vestibular Evoked Vestibular Evoked Not covered NA NA 92517, 92518, 92519 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0546T | Radiofrequency Radiofrequency Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0552T | Laser Therapy for Laser Therapy for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0559T | Three Dimensional (3- Three Dimensional (3- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0560T | Three Dimensional (3- Three Dimensional (3- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0561T | Three Dimensional (3- Three Dimensional (3- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0562T | D) Printed Anatomic D) Printed Anatomic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0563T | Meibomian Gland Meibomian Gland Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0564T | In Vitro In Vitro Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0565T | Stem Cell and Cellular Stem Cell and Cellular Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0566T | Stem Cell and Cellular Stem Cell and Cellular Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0569T | Transcatheter Heart Transcatheter Heart Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0571T | Cardiology - Cardiology - Required through , , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0572T | Cardiology - Cardiology - Required through , , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0573T | Cardiology - Cardiology - Required through , , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0574T | Cardiology - Cardiology - Required through , , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0584T | S2102. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0585T | S2102. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0586T | S2102. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0596T | situations. Review of the situations. Review of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0597T | actual policy is needed to actual policy is needed to 0220T, 0221T, 0222T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0598T | Wound Imaging and Wound Imaging and Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0600T | Irreversible Irreversible Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0601T | Irreversible Irreversible Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0604T | Scanning Laser Scanning Laser Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0605T | Scanning Laser Scanning Laser Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0606T | Scanning Laser Scanning Laser Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0615T | Eye-Movement Eye-Movement Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0616T | Iris Prosthesis Iris Prosthesis Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0617T | Iris Prosthesis Iris Prosthesis Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0618T | Iris Prosthesis Iris Prosthesis Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0620T | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0623T | This policy indicates This policy indicates | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0624T | has been identified as E/I has been identified as E/I | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0625T | has been identified as E/I has been identified as E/I | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0627T | nal (E/I) or Not Medically nal (E/I) or Not Medically | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0628T | Necessary (NMN). Some Necessary (NMN). Some | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0629T | Necessary (NMN). Some Necessary (NMN). Some | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0630T | Necessary (NMN). Some Necessary (NMN). Some | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0631T | situations. Review of the situations. Review of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0633T | • CT or MR | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0634T | • CT or MR | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0635T | included in the Carelon included in the Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0636T | included in the Carelon included in the Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0637T | included in the Carelon included in the Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0638T | included in the Carelon included in the Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0639T | coverage in specific coverage in specific | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0640T | Noncontact Near Noncontact Near Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0648T | • Low-field MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0651T | Wireless Capsule Wireless Capsule Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0656T | or NMN. or NMN | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0657T | This policy indicates This policy indicates | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0658T | has been identified as E/I has been identified as E/I | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0659T | or NMN. or NMN | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0692T | or NMN. or NMN | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0693T | *The list of codes is *The list of codes is | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0695T | *The list of codes is *The list of codes is | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0696T | *The list of codes is *The list of codes is | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0707T | Based and Bioactive Based and Bioactive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0745T | This policy indicates This policy indicates | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0746T | services which are services which are | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0747T | services which are services which are | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0776T | services which are services which are | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0783T | considered either considered either C9772, C9773, C9774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0795T | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0796T | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0797T | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0798T | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0799T | See Carelon website - See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0800T | See Carelon website - See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0801T | See Carelon website - See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0802T | See Carelon website - See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0803T | See Carelon website - See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0804T | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0858T | Stimulation Therapy Stimulation Therapy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0859T | Noncontact Near Noncontact Near Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0860T | Non-Contact Non-Contact Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0867T | Surgical and Minimally Surgical and Minimally Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0889T | Stimulation Therapy Stimulation Therapy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0890T | Stimulation Therapy Stimulation Therapy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0891T | MP9623 MP9623 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 0892T | MP9623 MP9623 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11055 | Foot Care MP9656 Foot Care MP9656 Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11056 | Foot Care MP9656 Foot Care MP9656 Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11057 | Foot Care MP9656 Foot Care MP9656 Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11719 | G0127, S0390 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11720 | G0127, S0390 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11721 | G0127, S0390 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11920 | Updated: September 1, 2025 Page 22 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11921 | Updated: September 1, 2025 Page 22 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11922 | Updated: September 1, 2025 Page 22 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11950 | Updated: September 1, 2025 Page 22 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11951 | 14001, 14041, 15734, 15738, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11952 | 14001, 14041, 15734, 15738, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 11954 | 14001, 14041, 15734, 15738, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 13999 | Electric Cell-Signaling Electric Cell-Signaling Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 14000 | 14001, 14041, 15734, 15738, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 14001 | 15750, 15757, 15758, 15769, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 14041 | 15750, 15757, 15758, 15769, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15271 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15272 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15273 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15274 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15275 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15276 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15277 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15278 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15734 | 15750, 15757, 15758, 15769, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15738 | 15750, 15757, 15758, 15769, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15750 | 15771, 15772, 15773, 15774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15757 | 15771, 15772, 15773, 15774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15758 | 15771, 15772, 15773, 15774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15769 | 15771, 15772, 15773, 15774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15771 | 15780, 15781, 15783, 15786, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15772 | 15780, 15781, 15783, 15786, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15773 | 15780, 15781, 15783, 15786, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15774 | 15780, 15781, 15783, 15786, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15777 | Q4197, Q4181, Q4183, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15780 | 15787, 15788, 15789, 15792, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15781 | 15787, 15788, 15789, 15792, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15783 | 15787, 15788, 15789, 15792, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15786 | 15787, 15788, 15789, 15792, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15787 | 15793, 15819, 15824, 15825, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15788 | 15793, 15819, 15824, 15825, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15789 | 15793, 15819, 15824, 15825, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15792 | 15793, 15819, 15824, 15825, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15793 | 15826, 15828, 15829, 15832, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15819 | 15826, 15828, 15829, 15832, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15820 | Cosmetic and Cosmetic and Required , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15821 | Cosmetic and Cosmetic and Required , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15822 | Cosmetic and Cosmetic and Required , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15823 | Cosmetic and Cosmetic and Required , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15824 | 15826, 15828, 15829, 15832, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15825 | 15826, 15828, 15829, 15832, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15826 | 15833, 15834, 15835, 15836, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15828 | 15833, 15834, 15835, 15836, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15829 | 15833, 15834, 15835, 15836, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15830 | Reconstructive Reconstructive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15832 | 15833, 15834, 15835, 15836, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15833 | 15837, 15838, 15876, 15878, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15834 | 15837, 15838, 15876, 15878, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15835 | 15837, 15838, 15876, 15878, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15836 | 15837, 15838, 15876, 15878, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15837 | 15879, 17380, 17999, 21137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15838 | 15879, 17380, 17999, 21137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15839 | Reconstructive Reconstructive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15847 | Reconstructive Reconstructive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15876 | 15879, 17380, 17999, 21137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15877 | Reconstructive Reconstructive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15878 | 15879, 17380, 17999, 21137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 15879 | 21138, 21139, 21172, 21175, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 17380 | 21138, 21139, 21172, 21175, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 17999 | 21138, 21139, 21172, 21175, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19300 | Male Gynecomastia Male Gynecomastia Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19301 | 19303, 19304, 19305, 19306, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19302 | 19303, 19304, 19305, 19306, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19303 | 19307, 19316, 19318, 19325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19304 | 19307, 19316, 19318, 19325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19305 | 19307, 19316, 19318, 19325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19306 | 19307, 19316, 19318, 19325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19307 | 19350, 53415, 53420, 53425, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19316 | 19350, 53415, 53420, 53425, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19318 | Female Breast Female Breast Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19325 | 19350, 53415, 53420, 53425, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19328 | Breast Implant Breast Implant Required , , , Breast implant NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19330 | Breast Implant Breast Implant Required , , , Breast implant NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19340 | Breast Implant Breast Implant Required , , , Breast implant NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19342 | Removal, Revision, or Removal, Revision, or , , , removal, revision, or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19350 | 53430, 54120, 54125, 54130, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19370 | Removal, Revision, or Removal, Revision, or , , , removal, revision, or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19371 | Removal, Revision, or Removal, Revision, or , , , removal, revision, or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19380 | Reimplantation Reimplantation reimplantation | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 19499 | Breast Ductal Lavage Breast Ductal Lavage Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20291 | Synthetic Cartilage Synthetic Cartilage Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20560 | Trigger Point Dry Trigger Point Dry Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20561 | Trigger Point Dry Trigger Point Dry Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20930 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20931 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20936 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20937 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20938 | Procedures, Spine Procedures, Spine Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20939 | Procedures, Spine Procedures, Spine Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20974 | Bone Growth Bone Growth Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20975 | Bone Growth Bone Growth Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20979 | Bone Growth Bone Growth Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 20999 | provided for informational provided for informational | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21085 | Orthognathic Surgery Orthognathic Surgery Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21110 | Orthognathic Surgery Orthognathic Surgery Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21120 | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21121 | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21122 | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21123 | Positive Airway Positive Airway | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21125 | MP9651 (III-SUR.32) MP9651 (III-SUR.32) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21127 | 21143, 21145, 21146, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21137 | 21138, 21139, 21172, 21175, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21138 | 21179, 21180, 21208, 21209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21139 | 21179, 21180, 21208, 21209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21141 | 21143, 21145, 21146, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21142 | 21143, 21145, 21146, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21143 | 21147, 21150, 21151, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21145 | 21147, 21150, 21151, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21146 | 21147, 21150, 21151, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21147 | 21154, 21155, 21159, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21150 | 21154, 21155, 21159, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21151 | 21154, 21155, 21159, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21154 | 21160, 21193, 21194, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21155 | 21160, 21193, 21194, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21159 | 21160, 21193, 21194, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21160 | 21195, 21196, 21198, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21172 | 21179, 21180, 21208, 21209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21175 | 21179, 21180, 21208, 21209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21179 | 21210, 21215, 21230, 21235, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21180 | 21210, 21215, 21230, 21235, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21193 | 21195, 21196, 21198, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21194 | 21195, 21196, 21198, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21195 | 21199, 21206, 21208, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21196 | 21199, 21206, 21208, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21198 | 21199, 21206, 21208, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21199 | Positive Airway Positive Airway | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21206 | 21210, 21215, 21247, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21208 | 21210, 21215, 21230, 21235, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21209 | 21210, 21215, 21230, 21235, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21210 | 21270, 21899, 31599, 31899, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21215 | 21270, 21899, 31599, 31899, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21230 | 21270, 21899, 31599, 31899, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21235 | 21270, 21899, 31599, 31899, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21247 | Updated: September 1, 2025 Page 42 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21270 | 40799, 53410, 56620, 56810, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21685 | D7943, D7944, D7945, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 21899 | 40799, 53410, 56620, 56810, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22206 | Procedures, Spine Procedures, Spine Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22207 | Procedures, Spine Procedures, Spine Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22208 | services: 22216, 22220, 22222, 22224, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22210 | services: 22216, 22220, 22222, 22224, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22212 | services: 22216, 22220, 22222, 22224, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22214 | services: 22216, 22220, 22222, 22224, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22216 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22220 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22222 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22224 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22226 | Cervical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22510 | Cervical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22511 | Cervical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22512 | Cervical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22513 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22514 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22515 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22526 | Intradiscal Intradiscal Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22527 | Intradiscal Intradiscal Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22532 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22533 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22534 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22548 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22551 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22552 | With/Without | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22554 | With/Without | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22556 | With/Without | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22558 | With/Without | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22585 | Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22590 | Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22595 | Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22600 | Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22610 | guidelines/ guidelines/ 22632, 22633, 22634, 22800, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22612 | guidelines/ guidelines/ 22632, 22633, 22634, 22800, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22614 | guidelines/ guidelines/ 22632, 22633, 22634, 22800, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22630 | guidelines/ guidelines/ 22632, 22633, 22634, 22800, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22632 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22633 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22634 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22800 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22802 | Updated: September 1, 2025 Page 36 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22804 | Updated: September 1, 2025 Page 36 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22808 | Updated: September 1, 2025 Page 36 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22810 | Updated: September 1, 2025 Page 36 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22812 | Click here for additional Click here for additional • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22818 | Click here for additional Click here for additional • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22819 | Click here for additional Click here for additional • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22830 | Click here for additional Click here for additional • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22840 | information on Carelon information on Carelon Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22841 | information on Carelon information on Carelon Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22842 | information on Carelon information on Carelon Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22843 | information on Carelon information on Carelon Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22844 | prior authorization. prior authorization. 22848, 22849, 22853, 22854, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22845 | prior authorization. prior authorization. 22848, 22849, 22853, 22854, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22846 | prior authorization. prior authorization. 22848, 22849, 22853, 22854, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22847 | prior authorization. prior authorization. 22848, 22849, 22853, 22854, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22848 | prior authorization. prior authorization | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22849 | prior authorization. prior authorization | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22853 | prior authorization. prior authorization | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22854 | prior authorization. prior authorization | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22856 | Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22857 | Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22858 | Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22859 | Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22860 | Note: Effective Note: Effective • Discectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22861 | Note: Effective Note: Effective • Discectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22862 | Note: Effective Note: Effective • Discectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22864 | Note: Effective Note: Effective • Discectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22865 | 10/01/2024, prior 10/01/2024, prior Foraminotomy& | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22867 | Motion Preserving Motion Preserving Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22868 | Motion Preserving Motion Preserving Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22869 | Motion Preserving Motion Preserving Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22870 | Posterior Inter- Posterior Inter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 22899 | provided for informational provided for informational | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23105 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23107 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23120 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23130 | Musculoskeletal Musculoskeletal Required through , , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23410 | Procedures, (Large) Procedures, (Large) Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23412 | Procedures, (Large) Procedures, (Large) Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23415 | Procedures, (Large) Procedures, (Large) Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23420 | Procedures, (Large) Procedures, (Large) Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23430 | Joint Surgery Joint Surgery services: 23460, 23462, 23465, 23466, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23440 | Joint Surgery Joint Surgery services: 23460, 23462, 23465, 23466, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23450 | Joint Surgery Joint Surgery services: 23460, 23462, 23465, 23466, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23455 | Joint Surgery Joint Surgery services: 23460, 23462, 23465, 23466, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23460 | Joint Surgery Joint Surgery services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23462 | Joint Surgery Joint Surgery services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23465 | Joint Surgery Joint Surgery services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23466 | Joint Surgery Joint Surgery services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23470 | See Carelon website: Hip | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23472 | See Carelon website: Hip | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23473 | See Carelon website: Hip | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23474 | See Carelon website: Hip | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 23700 | See Carelon website: https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27005 | purposes only and may purposes only and may | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27096 | Musculoskeletal Musculoskeletal Required through , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27120 | See Carelon website: https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27122 | See Carelon website: https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27125 | See Carelon website: https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27130 | https://guidelines.carel onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27132 | https://guidelines.carel onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27134 | https://guidelines.carel onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27137 | https://guidelines.carel onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27138 | onmedicalbenefitsman • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27278 | 10/01/2024, prior 10/01/2024, prior Foraminotomy& | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27279 | 10/01/2024, prior 10/01/2024, prior Foraminotomy& | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27280 | 10/01/2024, prior 10/01/2024, prior Foraminotomy& | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27306 | purposes only and may purposes only and may | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27331 | onmedicalbenefitsman • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27332 | onmedicalbenefitsman • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27333 | onmedicalbenefitsman • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27334 | agement.com/current- Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27335 | agement.com/current- Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27345 | agement.com/current- Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27403 | agement.com/current- Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27405 | agement.com/current- musculoskeletal- Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27407 | agement.com/current- musculoskeletal- Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27409 | agement.com/current- musculoskeletal- Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27412 | agement.com/current- musculoskeletal- Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27415 | Articular Cartilage Articular Cartilage | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27416 | musculoskeletal- guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27418 | musculoskeletal- guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27420 | musculoskeletal- guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27422 | guidelines/ Click here for additional Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27424 | guidelines/ Click here for additional Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27425 | guidelines/ Click here for additional Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27427 | guidelines/ Click here for additional Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27428 | information on Carelon • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27429 | information on Carelon • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27437 | information on Carelon • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27438 | information on Carelon • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27440 | prior authorization. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27441 | prior authorization. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27442 | prior authorization. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27443 | prior authorization. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27445 | Click here for additional • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27446 | Click here for additional • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27447 | Click here for additional • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27486 | Click here for additional • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27487 | information on Carelon Note: Effective Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27488 | information on Carelon Note: Effective Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27570 | information on Carelon Note: Effective Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 27602 | purposes only and may purposes only and may | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 28446 | information on Carelon Note: Effective Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 28890 | Extracorporeal Shock Extracorporeal Shock Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29805 | prior authorization. 10/01/2024, prior Procedures 29820, 29821, 29822, 29823, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29806 | prior authorization. 10/01/2024, prior Procedures 29820, 29821, 29822, 29823, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29807 | prior authorization. 10/01/2024, prior Procedures 29820, 29821, 29822, 29823, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29819 | prior authorization. 10/01/2024, prior Procedures 29820, 29821, 29822, 29823, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29820 | prior authorization. 10/01/2024, prior Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29821 | prior authorization. 10/01/2024, prior Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29822 | prior authorization. 10/01/2024, prior Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29823 | prior authorization. 10/01/2024, prior Procedures | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29824 | authorization for the • Autologous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29825 | authorization for the • Autologous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29826 | authorization for the • Autologous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29827 | authorization for the • Autologous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29828 | Note: Effective services listed in the Chondrocyte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29860 | Note: Effective services listed in the Chondrocyte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29861 | Note: Effective services listed in the Chondrocyte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29862 | Note: Effective services listed in the Chondrocyte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29863 | 10/01/2024, prior Implantation of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29866 | 10/01/2024, prior Implantation of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29867 | Articular Cartilage Articular Cartilage | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29868 | 10/01/2024, prior Implantation of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29870 | authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29871 | authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29873 | authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29874 | authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29875 | submitted to Carelon. the Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29876 | submitted to Carelon. the Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29877 | submitted to Carelon. the Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29879 | submitted to Carelon. the Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29880 | chart to the right will be Shoulder | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29881 | chart to the right will be Shoulder | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29882 | chart to the right will be Shoulder | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29883 | chart to the right will be Shoulder | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29884 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29885 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29886 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29887 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29888 | submitted to Carelon. • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29889 | submitted to Carelon. • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29892 | submitted to Carelon. • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29914 | submitted to Carelon. • Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29915 | part of being evaluated at • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 29916 | part of being evaluated at • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30400 | Surgery Surgery | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30410 | Surgery Surgery | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30420 | Surgery Surgery | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30430 | Surgery Surgery | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30435 | Abdominoplasty/ Abdominoplasty/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30450 | Abdominoplasty/ Abdominoplasty/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30460 | Abdominoplasty/ Abdominoplasty/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30462 | Abdominoplasty/ Abdominoplasty/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30465 | Panniculectomy Panniculectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30468 | Panniculectomy Panniculectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 30999 | not be all inclusive. not be all inclusive. 38999, 55899, 69779, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 31299 | not be all inclusive. not be all inclusive. 38999, 55899, 69779, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 31599 | 40799, 53410, 56620, 56810, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 31899 | 40799, 53410, 56620, 56810, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32850 | 32851, 32852, 32853, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32851 | 32854, 32855, 32856. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32852 | 32854, 32855, 32856. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32853 | 32854, 32855, 32856. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32854 | Magnetic Esophageal Magnetic Esophageal Required 43284 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32855 | Magnetic Esophageal Magnetic Esophageal Required 43284 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 32856 | Magnetic Esophageal Magnetic Esophageal Required 43284 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33206 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33207 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33208 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33212 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33213 | • Cardiac | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33214 | • Cardiac | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33215 | • Cardiac | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33216 | • Cardiac | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33217 | • Cardiac | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33218 | Resynchronizat | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33220 | Resynchronizat | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33221 | Resynchronizat | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33222 | Resynchronizat | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33223 | Resynchronizat | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33224 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33226 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33227 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33228 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33229 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33230 | cardiology-guidelines/ cardiology-guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33231 | cardiology-guidelines/ cardiology-guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33233 | cardiology-guidelines/ cardiology-guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33240 | cardiology-guidelines/ cardiology-guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33241 | cardiology-guidelines/ cardiology-guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33244 | Updated: September 1, 2025 Page 11 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33249 | Updated: September 1, 2025 Page 11 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33262 | Updated: September 1, 2025 Page 11 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33263 | Updated: September 1, 2025 Page 11 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33264 | Updated: September 1, 2025 Page 11 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33270 | Click here for additional Click here for additional • Diagnostic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33271 | Click here for additional Click here for additional • Diagnostic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33272 | Click here for additional Click here for additional • Diagnostic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33273 | Click here for additional Click here for additional • Diagnostic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33274 | Click here for additional Click here for additional • Diagnostic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33275 | information on Carelon information on Carelon Coronary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33289 | Wireless Pulmonary Wireless Pulmonary Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33930 | Heart Transplantation Heart Transplantation Required Prior authorization is NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33933 | Heart Transplantation Heart Transplantation Required Prior authorization is NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33935 | Heart Transplantation Heart Transplantation Required Prior authorization is NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33940 | High Frequency Chest High Frequency Chest Required E0483, A7025, A7026 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33944 | High Frequency Chest High Frequency Chest Required E0483, A7025, A7026 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33945 | High Frequency Chest High Frequency Chest Required E0483, A7025, A7026 NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 33999 | Cell Therapy for the Cell Therapy for the Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36465 | Varicose Vein and Varicose Vein and Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36466 | Varicose Vein and Varicose Vein and Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36470 | Varicose Vein and Varicose Vein and Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36471 | Venous Insufficiency Venous Insufficiency | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36473 | Venous Insufficiency Venous Insufficiency | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36474 | Venous Insufficiency Venous Insufficiency | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36475 | Treatments of the Treatments of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36476 | Treatments of the Treatments of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36478 | Treatments of the Treatments of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36479 | 37500, 37700, 37718, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36482 | 37500, 37700, 37718, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36483 | 37500, 37700, 37718, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36514 | Therapeutic Apheresis Therapeutic Apheresis Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36519 | Therapeutic Apheresis Therapeutic Apheresis Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 36522 | Extracorporeal Extracorporeal Not Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37220 | information on Carelon information on Carelon Coronary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37221 | information on Carelon information on Carelon Coronary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37224 | information on Carelon information on Carelon Coronary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37225 | information on Carelon information on Carelon Coronary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37226 | prior authorization. prior authorization. Angiography 37231, 92920, 92924, 92928, 92933, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37227 | prior authorization. prior authorization. Angiography 37231, 92920, 92924, 92928, 92933, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37228 | prior authorization. prior authorization. Angiography 37231, 92920, 92924, 92928, 92933, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37229 | prior authorization. prior authorization. Angiography 37231, 92920, 92924, 92928, 92933, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37230 | prior authorization. prior authorization. Angiography 37231, 92920, 92924, 92928, 92933, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37231 | prior authorization. prior authorization. Angiography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37500 | Updated: September 1, 2025 Page 58 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37700 | Updated: September 1, 2025 Page 58 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37718 | Updated: September 1, 2025 Page 58 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37722 | Lower Extremities Lower Extremities | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37735 | Lower Extremities Lower Extremities | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37760 | Lower Extremities Lower Extremities | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37761 | MP9241 MP9241 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37765 | MP9241 MP9241 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37766 | MP9241 MP9241 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37780 | Vestibular Evoked Vestibular Evoked Not covered NA NA 92517, 92518, 92519 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 37785 | Vestibular Evoked Vestibular Evoked Not covered NA NA 92517, 92518, 92519 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38204 | Transplantation Transplantation | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38205 | Transplantation Transplantation | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38206 | Transplantation Transplantation | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38207 | MP9611 MP9611 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38208 | MP9611 MP9611 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38209 | MP9611 MP9611 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38210 | 38213, 38214, 38215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38211 | 38213, 38214, 38215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38212 | 38213, 38214, 38215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38213 | 38230, 38232, 38240, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38214 | 38230, 38232, 38240, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38215 | 38230, 38232, 38240, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38230 | 38241, 38242, 38243, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38232 | 38241, 38242, 38243, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38240 | 38241, 38242, 38243, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38241 | S2150 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38242 | S2150 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38243 | S2150 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 38999 | Cell Therapy for the Cell Therapy for the Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 40799 | 58544, 58940, 64856, 64892, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 41512 | Tongue Based Tongue Based Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 41530 | Radiofrequency Radiofrequency Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 42145 | Positive Airway Positive Airway | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43206 | Confocal Laser Confocal Laser Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43229 | Endoscopic Endoscopic Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43252 | Confocal Laser Confocal Laser Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43257 | Endoscopic Endoscopic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43270 | Endoscopic Endoscopic Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43284 | Magnetic Esophageal Magnetic Esophageal Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43290 | Metabolic and Bariatric Metabolic and Bariatric Required , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43291 | Metabolic and Bariatric Metabolic and Bariatric Required , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43644 | Metabolic and Bariatric Metabolic and Bariatric Required , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43645 | Metabolic and Bariatric Metabolic and Bariatric Required , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43659 | • and require | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43770 | Surgery MP9319 Surgery MP9319 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43771 | Surgery MP9319 Surgery MP9319 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43773 | Surgery MP9319 Surgery MP9319 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43775 | 43845, 43846, 43847 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43842 | 43845, 43846, 43847 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43843 | 43845, 43846, 43847 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43845 | 43848, 43860, 43865, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43846 | 43848, 43860, 43865, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43847 | 43848, 43860, 43865, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43848 | 43886, 43888 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43860 | 43886, 43888 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43865 | 43886, 43888 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43886 | • 43659 and 43999 require | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43888 | • 43659 and 43999 require | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 43999 | • and require | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44132 | 44135, 44136, 44137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44133 | 44135, 44136, 44137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44135 | 44715, 44720, 44721, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44136 | 44715, 44720, 44721, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44137 | 44715, 44720, 44721, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44715 | 47135, 47140, 47141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44720 | 47135, 47140, 47141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 44721 | 47135, 47140, 47141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47133 | 44135, 44136, 44137, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47135 | 47142, 47143, 47144, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47140 | 47142, 47143, 47144, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47141 | 47142, 47143, 47144, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47142 | 47145, 47146, 47147. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47143 | 47145, 47146, 47147. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47144 | 47145, 47146, 47147. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47145 | Intradiscal Intradiscal Not covered NA NA 22526, 22527 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47146 | Intradiscal Intradiscal Not covered NA NA 22526, 22527 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 47147 | Intradiscal Intradiscal Not covered NA NA 22526, 22527 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48160 | (Pancreas Alone) (Pancreas Alone) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48550 | (Pancreas Alone) (Pancreas Alone) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48551 | (Pancreas Alone) (Pancreas Alone) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48552 | MP9616 MP9616 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48554 | MP9616 MP9616 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 48556 | MP9616 MP9616 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50300 | 50325, 50327, 50328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50320 | 50325, 50327, 50328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50323 | 50325, 50327, 50328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50325 | 50329, 50340, 50360, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50327 | 50329, 50340, 50360, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50328 | 50329, 50340, 50360, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50329 | 50365, 50370, 50380, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50340 | 50365, 50370, 50380, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50360 | 50365, 50370, 50380, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50365 | 50547. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50370 | 50547. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50380 | 50547. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 50547 | Laboratory Testing Laboratory Testing Not required NA Use applicable CPT or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 51715 | Urethral Bulking Urethral Bulking Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 52284 | Surgical and Minimally Surgical and Minimally Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53410 | 58544, 58940, 64856, 64892, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53415 | 53430, 54120, 54125, 54130, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53420 | 53430, 54120, 54125, 54130, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53425 | 53430, 54120, 54125, 54130, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53430 | 54135, 54400, 54401, 54405, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53705 | Madison, WI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53860 | Transvaginal and Transvaginal and Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 53899 | Extracorporeal Extracorporeal Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54120 | 54135, 54400, 54401, 54405, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54125 | 54135, 54400, 54401, 54405, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54130 | 54135, 54400, 54401, 54405, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54135 | 54520, 54522, 54660, 54690, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54400 | 54520, 54522, 54660, 54690, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54401 | 54520, 54522, 54660, 54690, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54405 | 54520, 54522, 54660, 54690, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54520 | 55175, 55180, 55866, 55970, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54522 | 55175, 55180, 55866, 55970, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54660 | 55175, 55180, 55866, 55970, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 54690 | 55175, 55180, 55866, 55970, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55175 | 55980, 56625, 56800, 56805, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55180 | 55980, 56625, 56800, 56805, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55866 | 55980, 56625, 56800, 56805, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55880 | Ultrasound (HIFU) and Ultrasound (HIFU) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55899 | not be all inclusive. not be all inclusive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55970 | 55980, 56625, 56800, 56805, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 55980 | 57106, 57107, 57109, 57110, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56099 | Address P.O. Box | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56620 | 58544, 58940, 64856, 64892, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56625 | 57106, 57107, 57109, 57110, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56800 | 57106, 57107, 57109, 57110, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56805 | 57106, 57107, 57109, 57110, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 56810 | 58544, 58940, 64856, 64892, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57106 | 57111, 57112, 57291, 57292, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57107 | 57111, 57112, 57291, 57292, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57109 | 57111, 57112, 57291, 57292, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57110 | 57111, 57112, 57291, 57292, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57111 | 57335, 58150, 58152, 58180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57112 | 57335, 58150, 58152, 58180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57291 | 57335, 58150, 58152, 58180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57292 | 57335, 58150, 58152, 58180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 57335 | 58200, 58210, 58260, 58262, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58150 | 58200, 58210, 58260, 58262, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58152 | 58200, 58210, 58260, 58262, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58180 | 58200, 58210, 58260, 58262, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58200 | 58263, 58267, 58270, 58275, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58210 | 58263, 58267, 58270, 58275, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58260 | 58263, 58267, 58270, 58275, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58262 | 58263, 58267, 58270, 58275, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58263 | 58280, 58285, 58290, 58291, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58267 | 58280, 58285, 58290, 58291, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58270 | 58280, 58285, 58290, 58291, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58275 | 58280, 58285, 58290, 58291, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58280 | 58292, 58293, 58294, 58541, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58285 | 58292, 58293, 58294, 58541, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58290 | 58292, 58293, 58294, 58541, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58291 | 58292, 58293, 58294, 58541, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58292 | 58542, 58543, 58550, 58552, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58293 | 58542, 58543, 58550, 58552, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58294 | 58542, 58543, 58550, 58552, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58541 | 58542, 58543, 58550, 58552, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58542 | 58553, 58554, 58570, 58571, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58543 | 58553, 58554, 58570, 58571, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58544 | 64896 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58550 | 58553, 58554, 58570, 58571, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58552 | 58553, 58554, 58570, 58571, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58553 | 58572, 58573, 58661, 58720 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58554 | 58572, 58573, 58661, 58720 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58570 | 58572, 58573, 58661, 58720 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58571 | 58572, 58573, 58661, 58720 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58572 | 11920, 11921, 11922, 11950, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58573 | 11920, 11921, 11922, 11950, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58578 | Surgical Interruption of Surgical Interruption of Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58661 | 11920, 11921, 11922, 11950, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58674 | Radiofrequency Radiofrequency Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58720 | 11920, 11921, 11922, 11950, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58940 | 64896 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 58999 | Vaginal Tactile Vaginal Tactile Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 61885 | Implantable Deep Implantable Deep Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 61886 | Implantable Deep Implantable Deep Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62263 | Epidural Lysis of Epidural Lysis of Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62264 | Epidural Lysis of Epidural Lysis of Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62280 | Musculoskeletal Musculoskeletal Required through , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62281 | Musculoskeletal Musculoskeletal Required through , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62282 | Procedures, Procedures, Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62287 | Laser Spine Surgeries Laser Spine Surgeries Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62292 | Procedures, Procedures, Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62320 | Procedures, Procedures, Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62321 | Interventional Pain Interventional Pain services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62322 | Interventional Pain Interventional Pain services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62323 | Interventional Pain Interventional Pain services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62324 | Management - Management - • Epidural | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62325 | Management - Management - • Epidural | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62326 | Management - Management - • Epidural | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62327 | Injection | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 62380 | Laminotomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63001 | Laminotomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63003 | Laminotomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63005 | Laminotomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63012 | authorization for the authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63015 | authorization for the authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63016 | authorization for the authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63017 | authorization for the authorization for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63020 | services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63030 | services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63035 | services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63040 | services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63042 | chart to the right will be • Fusion & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63043 | chart to the right will be • Fusion & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63044 | chart to the right will be • Fusion & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63045 | chart to the right will be • Fusion & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63046 | submitted to Carelon. Treatment of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63047 | submitted to Carelon. Treatment of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63048 | submitted to Carelon. Treatment of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63050 | submitted to Carelon. Treatment of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63051 | Spinal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63052 | Spinal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63053 | Spinal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63055 | Spinal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63056 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63057 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63075 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63076 | Procedures performed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63081 | on an emergent basis (as Procedures performed Deformity | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63082 | on an emergent basis (as Procedures performed Deformity | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63085 | on an emergent basis (as Procedures performed Deformity | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63086 | on an emergent basis (as Procedures performed Deformity | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63087 | part of being evaluated at on an emergent basis (as • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63088 | part of being evaluated at on an emergent basis (as • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63090 | part of being evaluated at on an emergent basis (as • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63091 | part of being evaluated at on an emergent basis (as • Disc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63101 | the ER and prior to the part of being evaluated at Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63102 | the ER and prior to the part of being evaluated at Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63103 | the ER and prior to the part of being evaluated at Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63185 | the ER and prior to the part of being evaluated at Arthroplasty | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63190 | the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63191 | the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63200 | the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63250 | the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63252 | patient’s discharge from | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63265 | patient’s discharge from | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63267 | patient’s discharge from | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63270 | patient’s discharge from | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63272 | the hospital) are not or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63275 | the hospital) are not or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63277 | the hospital) are not or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63280 | the hospital) are not or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63285 | included in the Carelon the hospital) are not Intertransverse | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63287 | included in the Carelon the hospital) are not Intertransverse | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63290 | included in the Carelon the hospital) are not Intertransverse | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63300 | included in the Carelon the hospital) are not Intertransverse | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63301 | MSK program. included in the Carelon Lumbar Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63302 | MSK program. included in the Carelon Lumbar Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63303 | MSK program. included in the Carelon Lumbar Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63304 | MSK program. included in the Carelon Lumbar Fusion | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63305 | MSK program | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63306 | MSK program | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63307 | MSK program | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63308 | MSK program | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63650 | Injection | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63655 | Injection | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63663 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63664 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63685 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 63688 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64451 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64479 | https://guidelines.carel https://guidelines.carel | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64480 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64483 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64484 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64490 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64491 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64492 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64493 | musculoskeletal- musculoskeletal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64494 | musculoskeletal- musculoskeletal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64495 | musculoskeletal- musculoskeletal | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64505 | Sphenopalatine Sphenopalatine Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64510 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64520 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64533 | Vagus Nerve Vagus Nerve Required , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64555 | Implantable Peripheral Implantable Peripheral Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64568 | Implanted Hypoglossal Implanted Hypoglossal Required , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64569 | Implanted Hypoglossal Implanted Hypoglossal Required , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64575 | Implantable Peripheral Implantable Peripheral Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64582 | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64584 | Home Use of Bilevel Home Use of Bilevel Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64625 | guidelines/ guidelines/ | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64628 | Blocks | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64629 | Blocks | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64633 | Blocks | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64634 | • Paraverte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64635 | • Paraverte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64636 | • Paraverte | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64856 | 64896 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64892 | 64896 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64896 | Genetic Testing: Genetic Testing: Not required NA Use applicable CPT or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 64999 | Electric Cell-Signaling Electric Cell-Signaling Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67900 | Panniculectomy Panniculectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67901 | Panniculectomy Panniculectomy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67902 | MP9646 MP9646 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67903 | MP9646 MP9646 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67904 | MP9646 MP9646 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67906 | MP9646 MP9646 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67908 | Blepharoplasty, Blepharoplasty, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67909 | Blepharoplasty, Blepharoplasty, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 67999 | has been identified as E/I has been identified as E/I 0624T, 0625T, 0658T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69300 | Blepharoplasty, Blepharoplasty, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69705 | Eustachian Tube Eustachian Tube Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69706 | Eustachian Tube Eustachian Tube Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69710 | Bone Anchored Bone Anchored Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69711 | Bone Anchored Bone Anchored Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69714 | Bone Anchored Bone Anchored Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69715 | Hearing Aid MP9018 Hearing Aid MP9018 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69716 | Hearing Aid MP9018 Hearing Aid MP9018 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69717 | Hearing Aid MP9018 Hearing Aid MP9018 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69719 | 69730, L8690, L8691, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69728 | 69730, L8690, L8691, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69729 | 69730, L8690, L8691, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69730 | L8692, L8693, L8694, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 69779 | not be all inclusive. not be all inclusive | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70336 | Radiology Services - Radiology Services - Required through | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70450 | Radiology Services - Radiology Services - Required through | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70460 | Radiology Services - Radiology Services - Required through | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70470 | Radiology Services - Radiology Services - Required through | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70480 | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70481 | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70482 | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70486 | Carelon for these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70487 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70488 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70490 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70491 | See Carelon website: See Carelon website | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70492 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70496 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70498 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70540 | services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70542 | Selected | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70543 | Selected | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70544 | Selected | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70545 | Selected | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70546 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70547 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70548 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70549 | onmedicalbenefitsman onmedicalbenefitsman | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70551 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70552 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70553 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70554 | agement.com/current- agement.com/current | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 70555 | the following | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71250 | the following | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71260 | the following | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71270 | the following | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71271 | • Computed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71275 | • Computed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71550 | • Computed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71551 | • Computed | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71552 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 71555 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72125 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72126 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72127 | Click here for additional Click here for additional (CT) 72131, 72132, 72133, 72141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72128 | Click here for additional Click here for additional (CT) 72131, 72132, 72133, 72141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72129 | Click here for additional Click here for additional (CT) 72131, 72132, 72133, 72141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72130 | Click here for additional Click here for additional (CT) 72131, 72132, 72133, 72141, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72131 | Click here for additional Click here for additional (CT) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72132 | Click here for additional Click here for additional (CT) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72133 | Click here for additional Click here for additional (CT) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72141 | Click here for additional Click here for additional (CT) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72142 | information on Carelon information on Carelon • Low-dose CT | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72146 | information on Carelon information on Carelon • Low-dose CT | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72147 | information on Carelon information on Carelon • Low-dose CT | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72148 | information on Carelon information on Carelon • Low-dose CT | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72149 | prior authorization. prior authorization. • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72156 | prior authorization. prior authorization. • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72157 | prior authorization. prior authorization. • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72158 | prior authorization. prior authorization. • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72159 | resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72191 | resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72192 | resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72193 | resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72194 | Note: Effective Note: Effective imaging (MRI) 72198, 73200, 73201, 73202, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72195 | Note: Effective Note: Effective imaging (MRI) 72198, 73200, 73201, 73202, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72196 | Note: Effective Note: Effective imaging (MRI) 72198, 73200, 73201, 73202, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72197 | Note: Effective Note: Effective imaging (MRI) 72198, 73200, 73201, 73202, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 72198 | Note: Effective Note: Effective imaging (MRI) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73200 | Note: Effective Note: Effective imaging (MRI) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73201 | Note: Effective Note: Effective imaging (MRI) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73202 | Note: Effective Note: Effective imaging (MRI) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73206 | 10/01/2024, prior 10/01/2024, prior • Functional | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73218 | 10/01/2024, prior 10/01/2024, prior • Functional | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73219 | 10/01/2024, prior 10/01/2024, prior • Functional | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73220 | 10/01/2024, prior 10/01/2024, prior • Functional | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73221 | authorization for the authorization for the MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73222 | authorization for the authorization for the MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73223 | authorization for the authorization for the MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73225 | authorization for the authorization for the MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73700 | services listed in the services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73701 | services listed in the services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73702 | services listed in the services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73706 | services listed in the services listed in the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73718 | 73722, 73723, 73725, 74150, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73719 | 73722, 73723, 73725, 74150, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73720 | 73722, 73723, 73725, 74150, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73721 | 73722, 73723, 73725, 74150, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73722 | Updated: September 1, 2025 Page 46 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73723 | Updated: September 1, 2025 Page 46 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 73725 | Updated: September 1, 2025 Page 46 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74150 | Updated: September 1, 2025 Page 46 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74160 | chart to the right will be chart to the right will be • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74170 | chart to the right will be chart to the right will be • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74174 | chart to the right will be chart to the right will be • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74175 | chart to the right will be chart to the right will be • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74176 | submitted to Carelon. submitted to Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74177 | submitted to Carelon. submitted to Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74178 | submitted to Carelon. submitted to Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74181 | submitted to Carelon. submitted to Carelon | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74182 | spectroscopy 74262, 74263, 74712, 75557, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74183 | spectroscopy 74262, 74263, 74712, 75557, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74185 | spectroscopy 74262, 74263, 74712, 75557, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74261 | spectroscopy 74262, 74263, 74712, 75557, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74262 | spectroscopy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74263 | spectroscopy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 74712 | spectroscopy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75261 | • Authorizations for members in our ASO (Administrative Services Only) plan types (payer ID ) should be submitted via email to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75557 | spectroscopy | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75559 | • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75561 | • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75563 | • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75571 | • Magnetic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75572 | those services performed those services performed resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75573 | those services performed those services performed resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75574 | those services performed those services performed resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75580 | those services performed those services performed resonance | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 75635 | cholangiopanc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76390 | cholangiopanc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76391 | Elastography Elastography Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76498 | Upright Magnetic Upright Magnetic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76981 | Elastography Elastography Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76982 | Elastography Elastography Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 76983 | (Ultrasound, Acoustic (Ultrasound, Acoustic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77046 | cholangiopanc | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77047 | during an inpatient stay) during an inpatient stay) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77048 | during an inpatient stay) during an inpatient stay) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77049 | during an inpatient stay) during an inpatient stay) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77078 | during an inpatient stay) during an inpatient stay) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 77084 | or on an emergent basis or on an emergent basis reatography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78429 | or on an emergent basis or on an emergent basis reatography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78430 | or on an emergent basis or on an emergent basis reatography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78431 | or on an emergent basis or on an emergent basis reatography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78432 | (i.e., those services (i.e., those services (MRCP) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78433 | (i.e., those services (i.e., those services (MRCP) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78451 | (i.e., those services (i.e., those services (MRCP) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78452 | (i.e., those services (i.e., those services (MRCP) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78453 | performed as part of performed as part of • Positron | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78454 | performed as part of performed as part of • Positron | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78459 | performed as part of performed as part of • Positron | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78466 | performed as part of performed as part of • Positron | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78468 | being evaluated at the being evaluated at the emission | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78469 | being evaluated at the being evaluated at the emission | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78472 | being evaluated at the being evaluated at the emission | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78473 | being evaluated at the being evaluated at the emission | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78481 | ER and prior to the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78483 | ER and prior to the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78491 | ER and prior to the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78492 | ER and prior to the ER and prior to the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78494 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78608 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78609 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78811 | tomography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78812 | patient’s discharge from patient’s discharge from (PET) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78813 | patient’s discharge from patient’s discharge from (PET) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78814 | patient’s discharge from patient’s discharge from (PET) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78815 | patient’s discharge from patient’s discharge from (PET) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 78816 | • CT or MR | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 81517 | Panel for Assessment Panel for Assessment HCPCS codes | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 82306 | Vitamin D Testing for Vitamin D Testing for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 82523 | Collagen Cross Links Collagen Cross Links Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 82652 | Vitamin D Testing for Vitamin D Testing for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83698 | Lipoprotein- Lipoprotein- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83700 | Lipoprotein Subclass Lipoprotein Subclass Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83701 | Lipoprotein Subclass Lipoprotein Subclass Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83704 | Lipoprotein Subclass Lipoprotein Subclass Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83772 | Testing for Screening, Testing for Screening | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 83987 | Exhaled Breath Tests Exhaled Breath Tests Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 86001 | Food Food Not required NA Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 86807 | Cytotoxic Testing for Cytotoxic Testing for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 86808 | Cytotoxic Testing for Cytotoxic Testing for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 90867 | Transcranial Magnetic Transcranial Magnetic Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 90868 | Transcranial Magnetic Transcranial Magnetic Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 90869 | Transcranial Magnetic Transcranial Magnetic Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 90870 | Outpatient and Outpatient and Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 91112 | Gastrointestinal Gastrointestinal Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 91200 | (Ultrasound, Acoustic (Ultrasound, Acoustic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92133 | Technologies for Technologies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92134 | Technologies for Technologies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92201 | Technologies for Technologies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92202 | Retina and Optic Retina and Optic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92499 | service is determined by service is determined by | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92517 | Vestibular Evoked Vestibular Evoked Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92518 | Vestibular Evoked Vestibular Evoked Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92519 | Vestibular Evoked Vestibular Evoked Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92548 | Computerized Computerized Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92549 | Computerized Computerized Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92618 | E2508, E2510, E2511, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92700 | service is determined by service is determined by | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92920 | prior authorization. prior authorization. Angiography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92924 | prior authorization. prior authorization. Angiography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92928 | prior authorization. prior authorization. Angiography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92933 | prior authorization. prior authorization. Angiography | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92937 | • Endovascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92943 | • Endovascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 92972 | Intravascular Intravascular Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93025 | situations. Review of the situations. Review of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93228 | Real-Time Mobile Real-Time Mobile Required , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93229 | Real-Time Mobile Real-Time Mobile Required , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93264 | Wireless Pulmonary Wireless Pulmonary Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93278 | coverage in specific coverage in specific | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93303 | • Endovascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93304 | • Endovascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93306 | • Endovascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93307 | Note: Effective Note: Effective Revascularizati | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93308 | Note: Effective Note: Effective Revascularizati | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93312 | Note: Effective Note: Effective Revascularizati | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93313 | Note: Effective Note: Effective Revascularizati | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93314 | Note: Effective Note: Effective Revascularizati | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93315 | 10/01/2024, prior 10/01/2024, prior on | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93316 | 10/01/2024, prior 10/01/2024, prior on | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93317 | 10/01/2024, prior 10/01/2024, prior on | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93350 | 10/01/2024, prior 10/01/2024, prior on | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93351 | 10/01/2024, prior 10/01/2024, prior on | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93356 | Myocardial Strain Myocardial Strain Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93454 | authorization for the authorization for the • Imaging of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93455 | authorization for the authorization for the • Imaging of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93456 | authorization for the authorization for the • Imaging of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93457 | authorization for the authorization for the • Imaging of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93458 | authorization for the authorization for the • Imaging of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93459 | services listed in the services listed in the Heart | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93460 | services listed in the services listed in the Heart | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93461 | services listed in the services listed in the Heart | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93580 | Transcatheter Closure Transcatheter Closure Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93581 | Transcatheter Closure Transcatheter Closure Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93582 | Transcatheter Closure Transcatheter Closure Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93701 | Thoracic Electrical Thoracic Electrical Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93702 | Bioimpedance Bioimpedance Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93740 | Thermography Thermography Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93799 | Non-invasive Non-invasive Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93880 | services listed in the services listed in the Heart | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93882 | chart to the right will be chart to the right will be • Implantable 93925, 93926, 93930, 93931, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93895 | Carotid Intima-Media Carotid Intima-Media Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93922 | chart to the right will be chart to the right will be • Implantable 93925, 93926, 93930, 93931, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93923 | chart to the right will be chart to the right will be • Implantable 93925, 93926, 93930, 93931, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93924 | chart to the right will be chart to the right will be • Implantable 93925, 93926, 93930, 93931, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93925 | chart to the right will be chart to the right will be • Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93926 | chart to the right will be chart to the right will be • Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93930 | chart to the right will be chart to the right will be • Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93931 | chart to the right will be chart to the right will be • Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93978 | submitted to Carelon. submitted to Carelon. Cardioverter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 93979 | submitted to Carelon. submitted to Carelon. Cardioverter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 94493 | bral Facet | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95012 | Exhaled Breath Tests Exhaled Breath Tests Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95027 | Serial Dilution Serial Dilution Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95199 | Nebulized Intranasal Nebulized Intranasal Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95803 | Actigraphy MP9559 Actigraphy MP9559 Not Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95807 | Facility-Based Facility-Based Required , , . NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95808 | Facility-Based Facility-Based Required , , . NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95810 | Facility-Based Facility-Based Required , , . NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95811 | Polysomnography Polysomnography - Please note: these | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95905 | Automated, Non- Automated, Non- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95940 | Intraoperative Intraoperative Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 95941 | Intraoperative Intraoperative Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96110 | Wireless Capsule Wireless Capsule Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96121 | Neuropsychological Neuropsychological Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96132 | Neuropsychological Neuropsychological Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96133 | Neuropsychological Neuropsychological Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96567 | Light Treatment and Light Treatment and Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96900 | Light Treatment and Light Treatment and Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96910 | Light Treatment and Light Treatment and Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96912 | Laser Therapies for Laser Therapies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96913 | Laser Therapies for Laser Therapies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96920 | Laser Therapies for Laser Therapies for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96921 | Benign Dermatologic Benign Dermatologic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 96922 | Benign Dermatologic Benign Dermatologic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97039 | service is determined by service is determined by | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97124 | Benefit coverage for any Benefit coverage for any | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97129 | Cognitive Cognitive Not required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97139 | Craniosacral Therapy Craniosacral Therapy Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97533 | Sensory and Auditory Sensory and Auditory Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97606 | Benefit coverage for any Benefit coverage for any | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97607 | Non-Powered or Non-Powered or Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97608 | Benefit coverage for any Benefit coverage for any | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 97610 | Noncontact, Low- Noncontact, Low- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98975 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98976 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98977 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98978 | Monitoring (RPM) and Monitoring (RPM) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98980 | Monitoring (RPM) and Monitoring (RPM) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 98981 | Monitoring (RPM) and Monitoring (RPM) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99091 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99453 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99454 | Remote Patient Remote Patient Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99457 | Monitoring (RPM) and Monitoring (RPM) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99458 | Monitoring (RPM) and Monitoring (RPM) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99473 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| 99474 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A0140 | Air Ambulance, Non- Air Ambulance, Non- Non-emergent air , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A1366 | of Durable Medical of Durable Medical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A2002 | Synthetic Ceramic- Synthetic Ceramic- Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4233 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4234 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4235 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4236 | of Durable Medical of Durable Medical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4520 | T4523, T4524, T4529, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4540 | Functional Electrical Functional Electrical Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4555 | Electric Tumor Electric Tumor Not covered NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4575 | Hyperbaric Oxygen Hyperbaric Oxygen Not required *Self-funded plans (ASO) Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4596 | Cranial Electrotherapy Cranial Electrotherapy Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4634 | E0625, E0605, E0710, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4638 | Equipment/Supplies Equipment/Supplies | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4639 | Equipment/Supplies Equipment/Supplies | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4649 | Sleep Studies for the Sleep Studies for the Required 95807, 95808, 95810, NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4660 | coverage of this service. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A4670 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A6000 | Non-Covered Medical Non-Covered Medical Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A6550 | Non-Covered Medical Non-Covered Medical Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A6560 | Non-Covered Medical Non-Covered Medical Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A6590 | Female External Female External Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A7025 | High Frequency Chest High Frequency Chest Required , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A7026 | High Frequency Chest High Frequency Chest Required , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A8001 | A8003, A8004, S0516, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A8002 | A8003, A8004, S0516, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A8003 | E0203, A4634, S9090, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A8004 | E0203, A4634, S9090, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A9272 | Non-Powered or Non-Powered or Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A9279 | Obstructive Sleep Obstructive Sleep | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A9281 | coverage of this service. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| A9291 | Procedures and Procedures and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4102 | Outpatient Enteral Outpatient Enteral Required , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4103 | Outpatient Enteral Outpatient Enteral Required , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4105 | Outpatient Enteral Outpatient Enteral Required , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4149 | Therapy MP9069 Therapy MP9069 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4150 | Therapy MP9069 Therapy MP9069 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4152 | Therapy MP9069 Therapy MP9069 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4153 | Amino Acid-Based Amino Acid-Based Not Required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4154 | B4157, B4158, B4159, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4155 | B4157, B4158, B4159, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4157 | B4160, B4161, B4162, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4158 | B4160, B4161, B4162, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4159 | B4160, B4161, B4162, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4160 | B4187 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4161 | Amino Acid-Based Amino Acid-Based Not Required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4162 | B4187 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| B4187 | Palatal Implants for Palatal Implants for Not covered NA NA C9757 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1062 | Experimental/Investigatio Experimental/Investigatio | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1721 | submitted to Carelon. submitted to Carelon. Cardioverter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1722 | Defibrillators | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1726 | Eustachian Tube Eustachian Tube Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1761 | Intravascular Intravascular Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1762 | C1763, C1781 C9250, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1763 | C9354 C9355 C9356 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1777 | Defibrillators | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1781 | C9354 C9355 C9356 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1785 | Defibrillators | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1786 | Defibrillators | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1817 | of Cardiac Defects of Cardiac Defects | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1821 | Posterior Inter- Posterior Inter | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1824 | considered either considered either C9772, C9773, C9774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1825 | considered either considered either C9772, C9773, C9774, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1839 | MP9715 MP9715 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1882 | Procedures performed in Procedures performed in • Percutaneous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1895 | Procedures performed in Procedures performed in • Percutaneous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1896 | Procedures performed in Procedures performed in • Percutaneous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C1899 | Procedures performed in Procedures performed in • Percutaneous | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C2619 | an inpatient setting (i.e., an inpatient setting (i.e | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C2620 | an inpatient setting (i.e., an inpatient setting (i.e | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C2621 | an inpatient setting (i.e., an inpatient setting (i.e | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C2624 | MAY be considered for MAY be considered for 64625, 62263, 62264, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7504 | feasible) C7507, C7508, E0748, 0095T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7505 | feasible) C7507, C7508, E0748, 0095T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7507 | feasible) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7508 | feasible) | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7531 | an inpatient setting (i.e., an inpatient setting (i.e | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7534 | Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7535 | Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7537 | Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7538 | Implantable | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7539 | during an inpatient stay) Pacemakers | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C7540 | during an inpatient stay) Pacemakers | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9250 | C9361, C9364, Q4137 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9352 | C9361, C9364, Q4137 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9353 | C9361, C9364, Q4137 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9354 | C9358 C9360 C9361, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9355 | C9358 C9360 C9361, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9356 | C9358 C9360 C9361, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9358 | C9364, C9399, A4649 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9359 | feasible) C7507, C7508, E0748, 0095T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9360 | C9364, C9399, A4649 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9361 | Q4227 Q4242 Q4276, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9362 | feasible) C7507, C7508, E0748, 0095T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9364 | Q4227 Q4242 Q4276, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9399 | Sleep Studies for the Sleep Studies for the Required 95807, 95808, 95810, NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9600 | during an inpatient stay) Pacemakers | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9601 | during an inpatient stay) Pacemakers | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9602 | • Vascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9603 | • Vascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9604 | • Vascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9605 | • Vascular | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9607 | Imaging | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9608 | Imaging | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9724 | MAY be considered for MAY be considered for 64625, 62263, 62264, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9734 | Ultrasound (HIFU) and Ultrasound (HIFU) and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9757 | Annulus Fibrosis Annulus Fibrosis Not Covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9772 | considered either considered either | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9773 | considered either considered either | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9774 | considered either considered either | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9775 | Experimental/Investigatio Experimental/Investigatio | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| C9781 | Procedures performed Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7940 | D7943, D7944, D7945, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7941 | D7943, D7944, D7945, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7943 | D7946, D7947, D7948, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7944 | D7946, D7947, D7948, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7945 | D7946, D7947, D7948, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7946 | D7949, D7950, D7995, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7947 | D7949, D7950, D7995, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7948 | D7949, D7950, D7995, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7949 | D7996 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7950 | D7996 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7995 | D7996 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| D7996 | Outpatient and Outpatient and Not required NA 90870 NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0118 | required for claims | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0189 | E0700, A8001, A8002, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0190 | Equipment MP9347 Equipment MP9347 Not covered *Please review policy to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0203 | E0625, E0605, E0710, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0210 | E1300, K1003, E0189, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0215 | E1300, K1003, E0189, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0218 | determine the criteria | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0240 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0244 | coverage of this service. | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0247 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0248 | Equipment MP9347 Equipment MP9347 Not covered *Please review policy to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0446 | Hyperbaric Oxygen Hyperbaric Oxygen Not required *Self-funded plans (ASO) Use applicable CPT or | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0470 | Pressure (BiPAP) for Pressure (BiPAP) for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0471 | Pressure (BiPAP) for Pressure (BiPAP) for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0472 | Pressure (BiPAP) for Pressure (BiPAP) for | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0483 | High Frequency Chest High Frequency Chest Required , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0485 | Conditions Other Than Conditions Other Than | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0486 | Conditions Other Than Conditions Other Than | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0601 | Conditions Other Than Conditions Other Than | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0605 | E1310 92618, E2506, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0625 | Equipment MP9347 Equipment MP9347 Not covered *Please review policy to | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0678 | Non-pneumatic Non-pneumatic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0679 | Non-pneumatic Non-pneumatic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0680 | Non-pneumatic Non-pneumatic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0681 | Compression Systems Compression Systems | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0682 | Compression Systems Compression Systems | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0700 | A8003, A8004, S0516, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0710 | E1310 92618, E2506, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0732 | Cranial Electrotherapy Cranial Electrotherapy Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0734 | Cala Trio Therapy for Cala Trio Therapy for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0747 | Stimulators -Electrical Stimulators -Electrical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0748 | Stimulators -Electrical Stimulators -Electrical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0749 | Stimulators -Electrical Stimulators -Electrical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0760 | (Long Bones) And (Long Bones) And | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0762 | Transcutaneous Transcutaneous Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0764 | Functional Electrical Functional Electrical Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0766 | Electric Tumor Electric Tumor Not covered NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0769 | Electrical or Electrical or Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0770 | Functional Electrical Functional Electrical Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0830 | Home Traction, Home Traction, Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0840 | Home Traction, Home Traction, Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0849 | Home Traction, Home Traction, Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0850 | Cervical and Lumbar Cervical and Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0855 | Cervical and Lumbar Cervical and Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0860 | Cervical and Lumbar Cervical and Lumbar | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0870 | MP9781 MP9781 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0880 | MP9781 MP9781 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0890 | MP9781 MP9781 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0900 | Home Use of Bilevel Home Use of Bilevel Not required NA 21120, 21121, 21122, 0437T, 64582, 64584 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0935 | determine the criteria | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0936 | determine the criteria | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E0941 | Home Use of Bilevel Home Use of Bilevel Not required NA 21120, 21121, 21122, 0437T, 64582, 64584 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1300 | E0700, A8001, A8002, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1310 | E2508, E2510, E2511, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1399 | CLEAR Institute CLEAR Institute Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1800 | Mechanical Stretching Mechanical Stretching Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1801 | Devices for the Devices for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1802 | Devices for the Devices for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1803 | Devices for the Devices for the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1805 | Treatment of Joint Treatment of Joint | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1806 | Treatment of Joint Treatment of Joint | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1810 | Treatment of Joint Treatment of Joint | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1811 | Contractures of the Contractures of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1812 | Contractures of the Contractures of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1815 | Contractures of the Contractures of the | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1816 | Extremities MP9659 Extremities MP9659 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1818 | Extremities MP9659 Extremities MP9659 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1820 | Extremities MP9659 Extremities MP9659 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1821 | E1831, E1840, E1841 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1825 | E1831, E1840, E1841 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1830 | E1831, E1840, E1841 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1831 | Mechanized Spinal Mechanized Spinal Not covered NA NA E0941 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1840 | Mechanized Spinal Mechanized Spinal Not covered NA NA E0941 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E1841 | Mechanized Spinal Mechanized Spinal Not covered NA NA E0941 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2001 | Female External Female External Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2120 | Experimental/Investigatio Experimental/Investigatio | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2506 | E2508, E2510, E2511, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2508 | E2512, E2599, *E1399, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2510 | E2512, E2599, *E1399, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2511 | E2512, E2599, *E1399, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2512 | * | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| E2599 | * | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0127 | Functional Electrical Functional Electrical Not required NA A4540, E0770, E0764, NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0182 | G9475 G9476 G9477 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0248 | Blood Coagulation Blood Coagulation Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0249 | Blood Coagulation Blood Coagulation Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0250 | Blood Coagulation Blood Coagulation Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0255 | Tests MP9727 Tests MP9727 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0260 | bral Facet | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0281 | Electrical or Electrical or Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0282 | Electrical or Electrical or Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0289 | part of being evaluated at • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0322 | Remote Therapeutic Remote Therapeutic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0337 | S0255 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0341 | 0584T, 0585T, 0586T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0342 | 0584T, 0585T, 0586T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0343 | 0584T, 0585T, 0586T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0428 | part of being evaluated at • Arthroscopy & | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0448 | Imaging | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0453 | Intraoperative Intraoperative Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G0465 | Autologous Blood- Autologous Blood- Not Covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G2170 | the member’s policy of the member’s policy of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G2171 | the member’s policy of the member’s policy of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9473 | G9475 G9476 G9477 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9474 | G9475 G9476 G9477 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9475 | MP9708 MP9708 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9476 | MP9708 MP9708 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9477 | MP9708 MP9708 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9478 | S0255 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| G9479 | S0255 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| J7308 | Benign Dermatologic Benign Dermatologic | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| J7309 | Conditions MP9057 Conditions MP9057 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| J7330 | Procedures performed Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| J7345 | Conditions MP9057 Conditions MP9057 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| K0108 | * | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| K0672 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| K1003 | E0700, A8001, A8002, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| K1007 | Powered Robotic Powered Robotic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| K1020 | Implantable MP9232 Implantable MP9232 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L2006 | Powered Robotic Powered Robotic Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L4010 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L4020 | Repairs/Replacement Repairs/Replacement Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L4030 | of Durable Medical of Durable Medical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L4130 | of Durable Medical of Durable Medical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5856 | Microprocessor Microprocessor Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5857 | Microprocessor Microprocessor Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5858 | Microprocessor Microprocessor Required , , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5859 | Controlled Knee Controlled Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5930 | Controlled Knee Controlled Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L5961 | Controlled Knee Controlled Knee | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6026 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6611 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6672 | L6682, L6684, L6686, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6680 | L6682, L6684, L6686, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6682 | L6687, L6688, L6689, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6684 | L6687, L6688, L6689, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6686 | L6687, L6688, L6689, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6687 | L6690, L7007, L7008, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6688 | L6690, L7007, L7008, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6689 | L6690, L7007, L7008, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6690 | L7009, L7045, L7180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6715 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6880 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6881 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6882 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6890 | Myoelectric Upper Myoelectric Upper Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6925 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6935 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6945 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6950 | Orthotics MP9637 Orthotics MP9637 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6955 | Orthotics MP9637 Orthotics MP9637 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6965 | Orthotics MP9637 Orthotics MP9637 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L6975 | L6682, L6684, L6686, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7007 | L7009, L7045, L7180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7008 | L7009, L7045, L7180, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7009 | L7181, L7190, L7191 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7045 | L7181, L7190, L7191 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7180 | L7181, L7190, L7191 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7181 | Nasal Expiratory Nasal Expiratory Not covered NA NA If a claim is submitted, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7190 | Nasal Expiratory Nasal Expiratory Not covered NA NA If a claim is submitted, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7191 | Nasal Expiratory Nasal Expiratory Not covered NA NA If a claim is submitted, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7367 | MP9106 MP9106 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7368 | MP9106 MP9106 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L7902 | MP9106 MP9106 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8514 | of Durable Medical of Durable Medical | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8603 | Urethral Bulking Urethral Bulking Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8604 | Urethral Bulking Urethral Bulking Not required NA , , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8606 | Agents for Urinary Agents for Urinary | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8641 | Synthetic Cartilage Synthetic Cartilage Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8642 | Synthetic Cartilage Synthetic Cartilage Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8681 | Equipment/Supplies Equipment/Supplies | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8684 | Equipment/Supplies Equipment/Supplies | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8689 | Equipment/Supplies Equipment/Supplies | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8690 | L8692, L8693, L8694, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8691 | L8692, L8693, L8694, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8692 | S2230, V5095 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8693 | S2230, V5095 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8694 | S2230, V5095 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8701 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| L8702 | Limb Prosthetics and Limb Prosthetics and | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| M0076 | Prolotherapy MP9726 Prolotherapy MP9726 Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| P2031 | Hair Analysis in the Hair Analysis in the Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| P9020 | Derived Products Derived Products | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4100 | Skin and Soft Tissue Skin and Soft Tissue Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4101 | Skin and Soft Tissue Skin and Soft Tissue Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4102 | Skin and Soft Tissue Skin and Soft Tissue Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4103 | Engineered Engineered | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4104 | Engineered Engineered | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4105 | Substitutes for Wound Substitutes for Wound | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4106 | Substitutes for Wound Substitutes for Wound | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4107 | and Surgical Care and Surgical Care | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4108 | and Surgical Care and Surgical Care | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4112 | MP9655 MP9655 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4113 | Skin and Soft Tissue Skin and Soft Tissue Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4114 | Skin and Soft Tissue Skin and Soft Tissue Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4115 | Engineered Engineered | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4116 | Q4157, Q4160, Q4161, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4117 | Engineered Engineered | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4118 | Engineered Engineered | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4121 | Q4157, Q4160, Q4161, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4122 | Q4132, Q4134, Q4165, Q4166, Q4167, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4123 | Substitutes for Wound Substitutes for Wound Q4105, Q4106, Q4128, Q4133, Q4135, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4126 | Substitutes for Wound Substitutes for Wound Q4105, Q4106, Q4128, Q4133, Q4135, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4127 | Substitutes for Wound Substitutes for Wound Q4105, Q4106, Q4128, Q4133, Q4135, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4128 | Substitutes for Wound Substitutes for Wound | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4130 | Q4132, Q4134, Q4165, Q4166, Q4167, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4132 | Q4151, Q4182, Q4169, Q4171, Q4173, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4133 | Substitutes for Wound Substitutes for Wound | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4134 | Q4151, Q4182, Q4169, Q4171, Q4173, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4135 | Substitutes for Wound Substitutes for Wound | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4136 | and Surgical Care and Surgical Care | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4137 | and Surgical Care and Surgical Care | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4138 | and Surgical Care and Surgical Care | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4139 | MP9655 MP9655 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4142 | MP9655 MP9655 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4143 | MP9655 MP9655 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4145 | Q4157, Q4160, Q4161, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4146 | Q4157, Q4160, Q4161, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4151 | Q4186, 15271, 15272, Q4174, Q4175, Q4176, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4153 | Q4157, Q4160, Q4161, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4157 | Q4122, Q4130, Q4162, Q4163, Q4164, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4160 | Q4122, Q4130, Q4162, Q4163, Q4164, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4161 | Q4122, Q4130, Q4162, Q4163, Q4164, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4162 | Q4132, Q4134, Q4165, Q4166, Q4167, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4163 | Q4132, Q4134, Q4165, Q4166, Q4167, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4164 | Q4132, Q4134, Q4165, Q4166, Q4167, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4165 | Q4151, Q4182, Q4169, Q4171, Q4173, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4166 | Q4151, Q4182, Q4169, Q4171, Q4173, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4167 | Q4151, Q4182, Q4169, Q4171, Q4173, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4169 | Q4186, 15271, 15272, Q4174, Q4175, Q4176, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4170 | Q4196, Q4197, Q4215 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4171 | Q4186, 15271, 15272, Q4174, Q4175, Q4176, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4173 | Q4186, 15271, 15272, Q4174, Q4175, Q4176, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4174 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4175 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4176 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4177 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4178 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4179 | Q4180, Q4184, Q4185, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4180 | 15276, 15277, 15278, Q4189, Q4190, Q4191, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4181 | Q4193, Q4198, Q4201, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4182 | Q4186, 15271, 15272, Q4174, Q4175, Q4176, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4183 | Q4193, Q4198, Q4201, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4184 | 15276, 15277, 15278, Q4189, Q4190, Q4191, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4185 | 15276, 15277, 15278, Q4189, Q4190, Q4191, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4186 | 15273, 15274, 15275, Q4177, Q4178, Q4179, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4188 | Q4196, Q4197, Q4215 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4189 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4190 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4191 | 15777 Q4192, Q4195, Q4196, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4192 | Q4197, Q4181, Q4183, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4193 | Q4203, Q4204, Q4205, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4195 | Q4197, Q4181, Q4183, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4196 | Q4197, Q4181, Q4183, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4197 | Q4193, Q4198, Q4201, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4198 | Q4203, Q4204, Q4205, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4201 | Q4203, Q4204, Q4205, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4203 | Q4206, Q4208, Q4209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4204 | Q4206, Q4208, Q4209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4205 | Q4206, Q4208, Q4209, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4206 | Q4210, Q4211, Q4212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4208 | Q4210, Q4211, Q4212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4209 | Q4210, Q4211, Q4212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4210 | Q4213, Q4214, Q4215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4211 | Q4213, Q4214, Q4215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4212 | Q4213, Q4214, Q4215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4213 | Q4217, Q4218, Q4219, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4214 | Q4217, Q4218, Q4219, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4215 | Q4217, Q4218, Q4219, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4217 | Q4220, Q4222, Q4226, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4218 | Q4220, Q4222, Q4226, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4219 | Q4220, Q4222, Q4226, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4220 | Q4227, Q4229, Q4230, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4222 | Q4227, Q4229, Q4230, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4226 | Q4227, Q4229, Q4230, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4227 | Q4231 Q4232 Q4233, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4229 | Q4231 Q4232 Q4233, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4230 | Q4231 Q4232 Q4233, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4231 | Q4234, Q4235, Q4236 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4232 | Q4234, Q4235, Q4236 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4233 | Q4234, Q4235, Q4236 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4234 | Updated: September 1, 2025 Page 51 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4235 | Updated: September 1, 2025 Page 51 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4236 | Updated: September 1, 2025 Page 51 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4237 | Q4241, Q4242, Q4244, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4238 | Q4241, Q4242, Q4244, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4240 | Q4241, Q4242, Q4244, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4241 | Q4245, Q4246, Q4247, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4242 | Q4245, Q4246, Q4247, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4244 | Q4245, Q4246, Q4247, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4245 | Q4248, Q4250 Q4252 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4246 | Q4248, Q4250 Q4252 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4247 | Q4248, Q4250 Q4252 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4248 | Q4253 Q4255, Q4166 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4250 | Q4253 Q4255, Q4166 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4251 | C9250 C9352, C9353, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4252 | Q4253 Q4255, Q4166 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4253 | Q4170 Q4188 Q4195, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4255 | Q4170 Q4188 Q4195, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4276 | Q4277, Q4278, Q4281, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4277 | Q4282, Q4283, Q4284, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4278 | Q4282, Q4283, Q4284, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4281 | Q4282, Q4283, Q4284, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4282 | Q4311, Q4312, Q4313, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4283 | Q4311, Q4312, Q4313, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4284 | Q4311, Q4312, Q4313, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4311 | Q4314, Q4315, Q4316, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4312 | Q4314, Q4315, Q4316, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4313 | Q4314, Q4315, Q4316, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4314 | Q4317, Q4318, Q4319, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4315 | Q4317, Q4318, Q4319, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4316 | Q4317, Q4318, Q4319, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4317 | Q4320, Q4321, Q4322, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4318 | Q4320, Q4321, Q4322, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4319 | Q4320, Q4321, Q4322, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4320 | Q4323, Q4324, Q4325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4321 | Q4323, Q4324, Q4325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4322 | Q4323, Q4324, Q4325, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4323 | Q4326, Q4327, Q4328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4324 | Q4326, Q4327, Q4328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4325 | Q4326, Q4327, Q4328, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4326 | Q4329, Q4330, Q4331, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4327 | Q4329, Q4330, Q4331, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4328 | Q4329, Q4330, Q4331, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4329 | Q4332, Q4333, C1762, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4330 | Q4332, Q4333, C1762, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4331 | Q4332, Q4333, C1762, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4332 | C1763, C1781 C9250, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q4333 | C1763, C1781 C9250, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5001 | Hospice (Inpatient and Hospice (Inpatient and Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5002 | Hospice (Inpatient and Hospice (Inpatient and Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5003 | Hospice (Inpatient and Hospice (Inpatient and Not required NA , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5004 | Outpatient) Services Outpatient) Services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5005 | Outpatient) Services Outpatient) Services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5006 | Outpatient) Services Outpatient) Services | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5007 | MP9299 MP9299 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5008 | MP9299 MP9299 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| Q5010 | MP9299 MP9299 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S0255 | Hyperbaric Oxygen Hyperbaric Oxygen Not required *Self-funded plans (ASO) Use applicable CPT or A4575, E0446 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S0390 | Functional Electrical Functional Electrical Not required NA A4540, E0770, E0764, NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S0516 | E0203, A4634, S9090, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S1091 | Drug Eluting Sinus Drug Eluting Sinus Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2060 | 32851, 32852, 32853, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2061 | 32851, 32852, 32853, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2065 | MP9617 MP9617 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2080 | Uvulopalatopharyngopl Uvulopalatopharyngopl Required NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2102 | Partial Hospitalization Partial Hospitalization Not required NA Use applicable CPT or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2112 | Procedures performed Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2117 | has been identified as E/I has been identified as E/I 0624T, 0625T, 0658T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2118 | Procedures performed Open | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2120 | Therapeutic Apheresis Therapeutic Apheresis Not required NA , , NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2150 | Breast Ductal Lavage Breast Ductal Lavage Not covered NA NA 19499 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2230 | MP9788 MP9788 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S2348 | actual policy is needed to actual policy is needed to 0220T, 0221T, 0222T, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S3650 | Salivary Hormone Salivary Hormone Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S3652 | Salivary Estriol Test Salivary Estriol Test Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8037 | • Low-field MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8042 | • Low-field MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8080 | Breast-Specific Breast-Specific Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8092 | • Low-field MRI | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8130 | Interferential Current Interferential Current Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8131 | Interferential Current Interferential Current Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S8948 | Laser Therapy for Laser Therapy for Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9055 | Derived Products Derived Products | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9090 | E0625, E0605, E0710, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9101 | the member’s policy of the member’s policy of | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9433 | required for claims | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9434 | required for claims | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9451 | Stimulation, Upper and Stimulation, Upper and *When used in | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9960 | Air Ambulance, Non- Air Ambulance, Non- Non-emergent air , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| S9961 | Air Ambulance, Non- Air Ambulance, Non- Non-emergent air , , NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T2036 | Wilderness Programs Wilderness Programs Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T2037 | Wilderness Programs Wilderness Programs Not covered NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T2039 | Durable Medical Durable Medical Not required or NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4521 | T4523, T4524, T4529, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4522 | T4523, T4524, T4529, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4523 | T4530, T4538, T4525, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4524 | T4530, T4538, T4525, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4525 | T4526, T4527, T4528, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4526 | T4529, T4531, T4532, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4527 | T4529, T4531, T4532, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4528 | T4529, T4531, T4532, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4529 | T4530, T4538, T4525, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4530 | T4526, T4527, T4528, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4531 | T4533, T4534, T4535, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4532 | T4533, T4534, T4535, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4533 | T4536, T4537, T4539, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4534 | T4536, T4537, T4539, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4535 | T4536, T4537, T4539, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4536 | Updated: September 1, 2025 Page 16 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4537 | Updated: September 1, 2025 Page 16 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4538 | T4526, T4527, T4528, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4539 | Updated: September 1, 2025 Page 16 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4540 | T4544, E0210, E0215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4541 | T4544, E0210, E0215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4543 | T4544, E0210, E0215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| T4544 | E1300, K1003, E0189, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5030 | Hearing Aids MP9445 Hearing Aids MP9445 Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5040 | Hearing Aids MP9445 Hearing Aids MP9445 Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5050 | Hearing Aids MP9445 Hearing Aids MP9445 Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5060 | V5095, V5100, V5120, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5070 | V5095, V5100, V5120, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5080 | V5095, V5100, V5120, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5095 | MP9788 MP9788 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5100 | Updated: September 1, 2025 Page 23 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5120 | Updated: September 1, 2025 Page 23 of 61 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5130 | V5171, V5172, V5181, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5140 | V5171, V5172, V5181, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5150 | V5171, V5172, V5181, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5171 | V5190, V5211, V5212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5172 | V5190, V5211, V5212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5181 | V5190, V5211, V5212, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5190 | V5213, V5214, V5215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5211 | V5213, V5214, V5215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5212 | V5213, V5214, V5215, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5213 | V5221, V5230, V5242, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5214 | V5221, V5230, V5242, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5215 | V5221, V5230, V5242, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5221 | V5243, V5244, V5245, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5230 | V5243, V5244, V5245, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5242 | V5243, V5244, V5245, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5243 | V5246, V5247, V5248, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5244 | V5246, V5247, V5248, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5245 | V5246, V5247, V5248, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5246 | V5249, V5250, V5251, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5247 | V5249, V5250, V5251, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5248 | V5249, V5250, V5251, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5249 | V5252, V5253, V5254, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5250 | V5252, V5253, V5254, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5251 | V5252, V5253, V5254, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5252 | V5255, V5256, V5257, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5253 | V5255, V5256, V5257, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5254 | V5255, V5256, V5257, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5255 | V5258, V5259, V5260, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5256 | V5258, V5259, V5260, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5257 | V5258, V5259, V5260, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5258 | V5261, V5262, V5263, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5259 | V5261, V5262, V5263, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5260 | V5261, V5262, V5263, | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5261 | V5298 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5262 | V5298 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5263 | V5298 | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5266 | Hearing Aids MP9445 Hearing Aids MP9445 Not required NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5298 | Heart\Lung Heart\Lung Required Prior authorization is NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |
| V5336 | Residential Treatment Residential Treatment Required Prior authorization is NA NA | 2024-10-01 | 2025-09-01 | 97% | [PDF] Medica Central Master Service List |