MP/CG Update/Notice - October 2024 Form

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Commercial services provided by Anthem Blue Cross, trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CM-070094-24 October 2024

California | Anthem Blue Cross | Commercial

October 1, 2024

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with the following updates. Please refer to the specific policy for coding, language, rationale updates and changes that are not summarized below.

NEW Medical Policies with prior authorization required effective January 1, 2025

• DME.00052 Brain Computer Interface Rehabilitation Devices: This document addresses non-implantable brain computer interface (BCI) rehabilitation devices. o Brain computer interface rehabilitation devices, including but not limited to electroencephalography (EEG)-driven upper extremity powered exercisers, are considered Investigational and Not Medically Necessary o Code E0738 for IpsiHand is considered Investigational and Not Medically Necessary for all indications

• LAB.00051 Per- and Polyfluoroalkyl Substances PFAS Testing: This document addresses testing for PFAS in humans, including but not limited to some of the most studied PFAS such as: perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), 2-(N-Methyl- perfluorooctane sulfonamido) acetic acid (MeFOSAA). o Testing for PFAS substances is considered Investigational and Not Medically Necessary for all indications o Codes 0394U and 0457U for PFAS tests, and codes 82542 and 83921 when specified as PFAS testing based on diagnosis are considered Investigational and Not Medically Necessary for all indications

• MED.00150 Hepzato Kit™ (melphalan hepatic delivery system): This document addresses Hepzato Kit™, a liver-directed therapy designed to administer high-dose melphalan via a hepatic arterial delivery system.
o Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for liver- directed administration of high-dose melphalan (Hepzato Kit) o Codes XW053T9, J9248 and 93799 are considered Medically Necessary when criteria are met

Updated Medical Policies effective January 1, 2025

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices: This document addresses certain types of electrical stimulation devices, including auricular electrostimulation, H-Wave stimulation, interferential stimulation therapy, microcurrent electrical nerve stimulation, pulsed electrical stimulation, percutaneous neuromodulation therapy, supraorbital transcutaneous neurostimulation, sympathetic therapies, cranial electrical stimulation and remote electrical neuromodulation. o Revised Investigational and Not Medically Necessary statement, adding external lower extremity nerve stimulator o Added codes A4543 and E0721 for Sparrow device and A4544 and E0743 for Tonic motor activation (TOMAC) device considered Investigational and Not Medically Necessary

• LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions: This document addresses the use of the systems pathology method for individuals with prostate cancer or Barrett’s esophagus, a condition that predisposes to the development of adenocarcinoma of the esophagus. o Revised title (previously titled Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer) o Added precancerous lesions with Barrett’s esophagus as an example to Position Statement o Added code 0108U for TissueCypher Barrett's Esophagus Assay, considered Investigational and Not Medically Necessary

• SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices: This document addresses the transcatheter closure of patent foramen ovale (PFO) and transcatheter or open left atrial appendage (LAA) closure. o Revised title (previously titled Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention) o Revised Medically Necessary statement o Added Not Medically Necessary statements for PFO and LAA closure o Added an Investigational and Not Medically Necessary statement for PFO

Carelon Medical Benefits Management, Inc. updates and expansion

Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

In the May 1, 2024, update letter, we informed you of an implementation delay of clinical appropriateness review for vascular and bariatric procedures included in the Carelon Expanded Cardiology program. Please be advised that prior authorization requirements will begin on March 1, 2025. (refer to Attachment B).

Pre-service review requirements
As we notified you in the July 1, 2024, provider notice, effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024. Please refer to the Clinical Guidelines and Medical Policies at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for clinical criteria, and Attachment B for a list of services and codes.

To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.

Clinical Appropriateness Reviews effective March 1, 2025 Effective March 1, 2025, the continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — Additional Outpatient UM (utilization management) that will include some

transportation (including ambulance) and fertility procedures. Transportation may include emergency post- service reviews. Please refer to Attachment B for a list of services and codes.

For more information and resources to help your practice get started with the programs, visit:

• Additional Outpatient UM: www.carelonmedicalbenefitsmanagement.com • Cardiovascular Solution: https://www.careloninsights.com/medical-benefits-management/specialty- care/cardiovascular • Radiology Solution: https://www.careloninsights.com/medical-benefits-management/radiology • Sleep Solution: https://www.careloninsights.com/medical-benefits-management/specialty-care/sleep • Surgical Procedures Solution: https://www.careloninsights.com/medical-benefits-management/specialty- care/surgical-procedures • Radiation Oncology Solution: https://www.careloninsights.com/medical-benefits-management/specialty- care/radiation-oncology

Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, Medical Policies and FAQs. You can also contact your local network relations representative if you have any questions.

For questions, please contact the provider service number on the back of the member's ID card.

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality health care for Californians.

Sincerely,

David Pryor, MD, MPH Chief Medical Officer

Attachment A – Revised Medical Policies and Clinical Guidelines effective October 1, 2024 Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes CG-MED-08 Home Enteral Nutrition • Revised oral enteral nutrition Medically Necessary statement to rearrange criterion and update language
• Revised enteral nutrition via tube Medically Necessary statement to align language with first position statement section CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins • Reformatted Medically Necessary criteria for transcatheter ablation CG-MED-69 Inhaled Nitric Oxide • Revised Medically Necessary criteria related to prior conventional therapies • Reformatted Not Medically Necessary section CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis • Revised Clinical Indications section to remove specific device names • Revised ‘myoelectric’ to ‘microprocessor controlled’ in repair and replacement Not Medically Necessary statements CG-REHAB-08 Private Duty Nursing in the Home Setting
• Revised Medically Necessary criteria section • Reformatted Medically Necessary and Not Medically Necessary sections CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty • Added code 61624 for stent embolization of aneurysm considered Medically Necessary when criteria are met CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies • Updated ICD-10-CM diagnosis codes, added E34.00-E34.09, E16.A1-E16.A3 CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity • Updated ICD-10-CM diagnosis codes, added E66.811-E66.813, E88.82, Z68.56 CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation • Updated ICD-10-CM diagnosis codes, added C84.9A, C84.AA, C84.ZA, C86.61, C88.00-C88.91 DME.00012 Intrapulmonary Percussive Ventilation Devices • Added codes A7021 and E0469 (replacing E1399) for Volara system as Investigational and Not Medically Necessary LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays • Added code 0511U for PARIS test considered Not Medically Necessary LAB.00015 Detection of Circulating Tumor Cells • Added codes 0490U, 0491U and 0492U for CELLSEARCH tests, considered Investigational and Not Medically Necessary LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer • Added code 0495U for Stockholm3 test considered Investigational and Not Medically Necessary LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia • Revised ‘diagnosis’ with ‘diagnose’ in the Investigational and Not Medically Necessary statement LAB.00050 Metagenomic Sequencing for Infectious Diseases in the Outpatient Setting • Added code 0480U for Mayo Clinic metagenomic test considered Investigational and Not Medically Necessary

MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring Systems • Revised title (previously titled Non-invasive Heart Failure and Arrhythmia Management and Monitoring System) • Revised Position Statement to remove device name and change from singular to plural devices • Added new devices AVIVO, VitalConnect, Zoe systems and BodyPort scale considered Investigational and Not Medically Necessary; added codes 93701 and E1399 MED.00135 Gene Therapy for Hemophilia • Added code C9172 for Beqvez considered Medically Necessary when criteria are met MED.00140
Gene Therapy for Beta Thalassemia
• Added new Medically Necessary statement regarding autologous hematopoietic stem cell mobilization and pheresis • Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures as Medically Necessary when criteria are met for gene therapy MED.00142
Gene Therapy for Cerebral Adrenoleukodystrophy
• Added new Medically Necessary statement regarding autologous hematopoietic stem cell mobilization and pheresis • Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures as Medically Necessary when criteria are met for gene therapy MED.00144 Gene Therapy for Duchenne Muscular Dystrophy • Revised wording in the Investigational and Not Medically Necessary statement to include the brand name “(ELEVIDYS)” and remove the phrase “for all other indications, including” • Removed codes C9399, J3490 and J3590, no longer applicable MED.00146 Gene Therapy for Sickle Cell Disease • Added new Medically Necessary statement regarding autologous hematopoietic stem cell mobilization and pheresis • Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures as Medically Necessary when criteria are met for gene therapy MED.00148 Gene Therapy for Metachromatic Leukodystrophy
• Added new Medically Necessary statement regarding autologous hematopoietic stem cell mobilization and pheresis • Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures as Medically Necessary when criteria are met for gene therapy SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis

• Revised title (changed the word ‘and’ to ‘or’) • Changed the word ‘and’ to ‘or’ in the Investigational and Not Medically Necessary statement • Added ICD-10-CM Q39.5 considered Medically Necessary for Peroral endoscopic myotomy (POEM) when criteria are met SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Added codes A2027, A2028, A2029, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345 for products considered Investigational and Not Medically Necessary SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures • Added ICD-10-PCS codes 0HRT07B, 0HRU07B, 0HRV07B for lumbar artery perforator flap for breast reconstruction when criteria are met SURG.00121 Transcatheter Heart Valve Procedures • Added ICD-10-PCS code X2RJ3RA for tricuspid valve replacement procedure considered Investigational and Not Medically Necessary SURG.00128 Implantable Left Atrial Hemodynamic Monitor • Added codes 0933T and 0934T effective January 1, 2025, considered Investigational and Not Medically Necessary

SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring • Added 64568 for new single-lead Inspire upper airway hypoglossal nerve stimulator considered Medically Necessary when criteria are met SURG.00135 Renal Sympathetic Nerve Ablation • Added ICD-10-PCS X05133A effective October 1, 2024 and code 0935T effective January 1, 2025 for renal nerve ablation considered Investigational and Not Medically Necessary
• Removed non-specific code 015M3ZZ SURG.00153 Cardiac Contractility Modulation Therapy • Added codes 0915T-0931T effective January 1, 2025 for cardiac contractility modulation-defibrillator systems, considered Investigational and Not Medically Necessary TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation • Added ICD-10-PCS code XW033DA for Lantidra, considered Investigational and Not Medically Necessary TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias • Reformatted allogeneic stem cell transplantation for multiple myeloma criteria • Revised Medically Necessary statements for autologous stem cell transplantation for initial treatment of primary amyloidosis • Removed criteria requiring left ventricular ejection fraction of 45% or greater • Added repeat autologous stem cell transplantation as a Medically Necessary treatment of relapsed amyloidosis when criteria are met • Revised Investigational and Not Medically Necessary statement TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome • Updated ICD-10-CM diagnosis codes, added C83.0A, C83.5A TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
• Updated ICD-10-CM diagnosis codes, added C81.9A, C85.9A, C86.61 TRANS.00038 Thymus Tissue Transplantation • Added code J3590 replacing L8699 for RETHYMIC

Attachment B – Carelon Updates and Expansion (new codes in bold below)

Program Clinical UM Guideline / Medical Policy
Codes Cardiovascular (effective October 1, 2024) MED.00111 Intracardiac Ischemia Monitoring 0525T, 0526T, 0527T, 0528T, 0529T, 0530T, 0531T, 0532T, C1833 MED.00115 Outpatient Cardiac Hemodynamic Monitoring w/Wireless Sensor for Heart Failure Management 33289, 93264, C2624 MED.00134 Non-Invasive Heart Failure and Arrhythmia Monitoring System 0607T, 0608T Musculoskeletal (effective October 1, 2024) CG-DME-45 Ultrasound Bone Growth Stimulation 20979 CG-MED-65 Manipulation Under Anesthesia 22505, 24300, 25259, 26340, 27275, 27860 CG-MED-78 Anesthesia for Interventional Pain Management Procedures 01941, 01942 CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury L8684 CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia 61790, 61791, 64600, 64605, 64610 SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons S2300 SURG.00114 Facet Joint Allograft Implants for Facet Disease 0221T, 0222T Radiation Oncology (effective October 1, 2024) THER-RAD.00008 Neutron Beam Radiotherapy 77423 Radiology (effective October 1, 2024) CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
76376, 76377 CG-MED-76 Magnetic Source Imaging & Magnetoencephalography 95965, 95966, 95967, S8035 RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray & Cineradiography/ Videofluoroscopy) 76120 RAD.00053 Cervical and Thoracic Discography 62291, 72285 Sleep (effective October 1, 2024) DME.00042 Electronic Positional Devices for Treatment of Obstructive Sleep Apnea E0530 DME.00043 Neuromuscular Electrical Training for Treatment of Obstructive Sleep Apnea E0490, E0491, E0492, E0493 Surgical GI (effective October 1, 2024) SURG.00116 High Resolution Anoscopy Screening 46601, 46607 SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization 46948

Program Clinical UM Guideline / Medical Policy
Codes Additional Outpatient Utilization Management Services (effective March 1, 2025) CG-ANC-04 Ambulance Services: Air and Water A0430, A0431, A0435, A0436, A0888, A0999, S9960, S9961 CG-ANC-06 Ambulance Services: Ground; Non- Emergent A0380, A0390, A0425, A0426, A0428, A0432, A0434, A0998 CG-MED-68 Therapeutic Apheresis 36511, 36512, 36513, 36514, 36516, 0342T, S2120 CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) 99183, G0277 CG-MED-88 Preimplantation Embryo Biopsy 89290, 89291

CG-MED-89 Home Parenteral Nutrition B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, S9364, S9365, S9366, S9367, S9368 CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) 89280, 89281

Program Clinical UM Guideline / Medical Policy
Codes Additional Outpatient Utilization Management Services, continued (effective March 1, 2025) DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices 0278T, 0720T, 0766T, 0767T, 0783T, A4540, E0732, S8130, S8131, S8930 DME.00048 Virtual Reality-Assisted Therapy Systems 0770T, 0771T, 0772T, 0773T, 0774T, E1905 LAB.00045 Selected Tests for the Evaluation and Management of Infertility 86357, 89329, 89330, 0253U, 0255U MED.00002 Selected Sleep Testing Services 95803, S8040 MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography) 96904, 96931, 96932, 96933, 96934, 96935, 96936, 0658T, 0700T, 0701T MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State S9056 MED.00082 Quantitative Sensory Testing 0106T, 0107T, 0108T, 0109T, 0110T, G0255 MED.00092 Automated Nerve Conduction Testing 95905, G0255 MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s) 0778T MED.00103 Automated Evacuation of Meibomian Gland 0330T MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema 93702 MED.00112 Autonomic Testing 95921, 95922, 95923, 95924 MED.00118 Continuous Monitoring of Intraocular Pressure 0329T MED.00130 Surface Electromyography Devices for Seizure Monitoring S3900 MED.00131 Electronic Home Visual Field Monitoring 0378T, 0379T MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion 0615T MED.00141 High-volume Colonic Irrigation 0736T Cardiovascular Vascular Services (effective March 1, 2025) CG-SURG-28 Transcatheter Uterine Artery Embolization 37243, 37244 CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty 37216, 37246, 61640, 61641, 61642 CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity 37242 CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction 36901, 36902, 36903, 36905, 36906, 36907, 36908, C7513, C7514, C7515, C7530 CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone 37238, 37239, 37248, 37249

CG-SURG-119 Treatment of Varicose Veins (Lower Extremities) 36465, 36466, 36468. 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37241, 0524T, S2202 RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver 37243 SURG.00062 Vein Embolization as a Treatment of Pelvic Congestion Syndrome and Varicocele 37241 SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices 0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, C1825

Program Clinical UM Guideline / Medical Policy
Codes Surgical Procedures (effective March 1, 2025) CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting 00170, 99151, 99152, 99153, 99155, 99156, 99157, D9222, D9223, G0330 CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing System 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 64575, 64590, 93150, 93151, 93152, 93153, C1778, C1816, C1823, L8680, L8682, L8683 CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications 55880, C9734 CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908 CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury L8680, L8682 CG-SURG-09 Temporomandibular Disorders 20605, 20606, 21010, 21050, 21060, 21073, 21110, 21116, 21210, 21240, 21242, 21243, 29800, 29804, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871, D7873, D7874, D7875, D7876, D7877, D7880, D9950, D9951, D9952 CG-SURG-12 Penile Prosthesis Implantation 54400, 54401, 54405, 54410, 54411, 54416, 54417, C1813, C2622 CG-SURG-18 Septoplasty 30520, 30620 CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) 31237, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, S2342 CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation of Solid Tumors Outside the Liver 19105, 20982, 20983, 32994, 32998, 50542, 50592, 50593, 53850, 53852, 55873, 0581T, 0673T CG-SURG-71 Reduction Mammaplasty 15877, 19318 CG-SURG-73 Balloon Sinus Ostial Dilation 31295, 31296, 31297, 31298, C1726 CG-SURG-79 Implantable Infusion Pumps 36260, 36261, 36563, 36583, 61215, 62350, 62351, 62360, 62361, 62362, C1772, C1891, C2626 CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants 69930, L8614, L8619, L8627, L8628, S2235

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids 69710, 69714, 69716, 69717, 69719, 69729, 69730, L8690, L8691, L8692, L8693, L8694, V5298 CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity 43290, 43291, 43770, 43772, 43773, 43774, 43842, 43886, 43887, 43888 CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21150, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21244, 21245, 21246, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996 CG-SURG-88 Mastectomy for Gynecomastia 15877, 19300 CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention 64561, 64566, 64581, 64585, 64590, 0587T, 0588T, 0786T, 0787T, 0816T, 0817T, 0818T, 0819T, C1767, C1820, C1883, L8679, L8680, L8685, L8686 CG-SURG-96 Intraocular Telescope 0308T, C1840 Program Clinical UM Guideline / Medical Policy
Codes Surgical Procedures, continued (effective March 1, 2025) CG-SURG-99 Panniculectomy and Abdominoplasty 15830, 15847, 15877 CG-SURG-105 Corneal Collagen Cross-Linking 0402T, J2787 CG-SURG-117 Balloon Dilation of the Eustachian Tubes 69705, 69706 CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) 66183, 66989, 66991, 0253T, 0449T, 0450T, 0474T, 0671T CG-SURG-120 Vagus Nerve Stimulation 61885, 64553, 64568, 64569, 95976, 95977, C1778, E0735, L8679, L8680, L8685, L8686 ANC.00007 Cosmetic and Reconstructive Services: Skin Related 11920, 11921, 11922, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17106, 17107, 17108, 17380 MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications 0071T, 0072T, 0398T, C9734 MED.00103 Automated Evacuation of Meibomian Gland 0207T, 0563T MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures 11950, 11951, 11952, 11954, 15771, 15772, 15773, 15774, 31574, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, C1878, G0429, L8607, Q2026, Q2028 SURG.00010 Treatments for Urinary Incontinence 51715, 53445, 53446, 53447, 53449, 53451, 53452, 53453, 53454, 53860, 0596T, 0597T, 0672T, C1815

SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting 15150, 15151, 15152, 15155, 15156, 15157, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777, 31574, 46707, 65778-65780, 0627T, 0628T, 0629T, 0630T, A2001, A2002, A2004-A2021, A2025, A4100, C5271-C5278, C9352-C9356, C9358, C9360, C9361, C9363, C9364, Q4100-Q4108, Q4110- Q4118, Q4121-Q4128, Q4130, Q4132-Q4143, Q4145-Q4171, Q4173- Q4181, Q4183-Q4206, Q4208, Q4209, Q4211-Q4222, Q4224- Q4227, Q4229-Q4242, Q4245- Q4276, Q4278-Q4284, Q4287- Q4304, Q4310, V2790 SURG.00045 Extracorporeal Shock Wave Therapy 28890, 0101T, 0102T, 0512T, 0864T SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses V2787, V2788 SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided 58580, 58674 SURG.00079 Nasal Valve Repair 30468, 30469 SURG.00084 Implantable Middle Ear Hearing Aids S2230, V5095 SURG.00095 Viscocanalostomy and Canaloplasty 66174, 66175 SURG.00096 Surgical and Ablative Treatments for Chronic Headaches 14040, 14041, 14060, 14061, 15824, 15826, 64716, 64722, 64732, 64734, 64744, 64771, 64772, 67900 SURG.00107 Prostate Saturation Biopsy 55706 SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) 64575, C1767 SURG.00118 Bronchial Thermoplasty 31660, 31661 SURG.00120 Internal Rib Fixation Systems 21811, 21812, 21813 SURG.00126 Irreversible Electroporation (IRE) 0600T, 0601T Program Clinical UM Guideline / Medical Policy
Codes Surgical Procedures, continued (effective March 1, 2025) SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 41512, 41530, 42145, 64582, C1767, C1778, C1787, C9727, D7940, D7941, D7943, D7944, D7945, D7946, D7947, L8680, L8681, L8688, S2080 SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency J7402, S1091 SURG.00135 Renal Sympathetic Nerve Ablation 0338T, 0339T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0351T, 0352T, 0353T, 0354T, 0546T SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
64405, 64450 SURG.00156 Implanted Artificial Iris Devices 0616T, 0617T, 0618T, C1839

SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis 31242, 31243 SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer 0655T SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease 67027, J2779 MCG: GRG: Urologic Surgery or Procedure GRG 53854 MCG : ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy 58145 MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal 58263, 58270, 58292, 58294, 58260, 58262, 58290, 58291 MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic 58541, 58542, 58543, 58544, 58550, 58553 MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy 58545, 58546 Musculoskeletal (effective March 1, 2025) SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) 61885, 64553, 64555, 64568, 64569, 64590, C1778, L8679, L8680, L8685, L8686 SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain 64415, 64417, 64447, 64450 SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain 64555, 64575, 64590, 64596, 64597, C1767, C1778, C1787, L8678, L8679, L8680, L8681, L8683